04060118 CITY OF CUPERTINO
BUILDING DIVISION PERMIT ' CONTItACTQRINFORMATION `,,
BUILDING ADDRESS: RICH MADDEN PEKMITND04060118
OWNER'S NAME: PERMIT LSSUE DATE
RICH
E:
SANITARY N0. CONTROL NO.
(408) 866-1;4r7
ARCHITE-CTIENGINEER
08 6 -
ARCHITECTIENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
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uoa LICENSED CONTRACTOR'S DECLARATION M
UZJob Description
1 herby affirm tial 1 am licensed under previsions of Chapter 9(commencing P
with Scaim7M0)of Division Sof NC Business and Professions Code,and my license is
in full to=Li..Cl and effect. REVISION--IN HOUSE USE ONLY
Z; License Claes Lk.M
Dam Contractor NO NEW PERMIT ISSUED/ ORIG. 403110121
q�q ARCHITECTS DECLARATION
g< 1 understand my plans dull x uuJ as public rtmrds
JyU
LL
Licensed Pnrfessionel C
i0 OWNER-BUILDER DECLARATION
CmarION
zoo 1 booby.Sect that I ore cBusin from Ne Cantmts Co :Any Lew for the
pO following ersel" 711ma Business andme,deigns h.a,Any oily arecounty S'
m� which roquirts a Pemtit m mwnu4 alcor,improve,dcmnlish.stn rtPolr-any suucturt
FZ< prior m its issumce,.I.acqsires lhcapplasmforsuch permit to file•signcd aumment
Nal he is licensed pursuant m the provisions of she Contractor's Umnse Law(Chapter 9 Sq. Ft. Floor Area ��Valua[io 1107
z�0 (commencing with Se[II0a 7")of Division 3 of the Business end Professions Count or
i $ sm,he is exempt lMrefrom and she basis for the alleged eremption.Any violation of
Section 7031.5 by arty applicant far a Permit subjects tits epplicanuo a civil .all,of APN Number Occupancy Type
not more Nan five hundred dollars(SSW).
E]
1.as owner of the property,or my employees wish Miss u their sole compensation, 37517009 . 00
will do the walk arse restructure is nm inmodW as offered fonue(See 9044.Business Required Inspections
and pmfesioss Code:The Conudao am License Law danest apply m an ower of tl p
Instancy who builds or improvms themon,and whodoessuch work himself or through his
own employers,pmvidcd that such improvements tie not intended or offered for sale.If.
IS however,the building or improvement is old within one year of completion,the owner.
builder wi0 have the burden of proving that x did non Wild or improve for purpose of
sale.).
I,as owner of the property,am exdmivdy convening with licensed estnuacmra m
cobwn the pmjett(gee 7044,Business and Profusions CWc:)The Conwcmrh Li-
PP law does not aly m in owner of property who builds or improves thereon,and,
who contracts for such Partners with a conuactoo(s)licensed pursuant to the Comnctar's
License Law.
❑lam e¢mpl ere Rc. .B&PC far shO moan
Own,
WOR ER'S COMPENSATION DECD ON
1 hereby affirm under penury of perjury am of tx following decimations:
bare and will maintain a Certifiam ofCona mmself-insumfmWorker'sCompen-
ma,a Provided for by Section 37W of tx labor Code.for the performanan of the
work for which this permit is issued.
0 1 have and will mun nein Worker's Compensation Insurance,ns ryuimd by Section
3700 of the labor Code,for the penformatre of the wort far which Nis permit is issuW.
My Worker's Compensation Insurance artier and Policy number art:
Carrier: Polity No.:
CERTIFICATE OF EXEMPITON FROM WORKERS'
COMPENSATION INSURANCE
front uctlnn need not x completed if the Permit is for one hundred dollars(SIM)
or less.)
1 unify than in the perfmauu cc of the,.,it for which this Permit is issued.l shell not
employ any person in any manmrse as to became subject in the Workers Compmemon
Laws of California.Dam
Applicant
NOTICE TO APPLICANT.If,after making Nu Contra.¢of Exemption,you should
become subject as tx Worked Compensation previsions of dw IaWr Crak,you muse
,J Z forthwith comply with such provisions or this Permit shall be dccmcd revoked.
z CONSTRUCTION LENDING AGENCY .
[-. 1 heraby.frove Nm there is a eonsu Minn lending agency,lot tx Performance of
fLa? she work fur which this permit is issued(Sec.3091,Co.C.) !J
W Q Lender's Name
11 Lender's Address '
VC) I unify that 1 have reed this application arta sou that she above information u '
W Fcocoa 1 ague to comply with all city and county ordinances and sum lows relating to
C) building convection.and hereby mutation reprseanatiws of this city to enter upon the
r W above-mentioned property for inspection purposes. non
CL (We)agree to sass.Indemnify and keep harmksi she City of Cupertino agaiwt
nFi h Iiabiliues.judgmtos.eosu and expenses which may in my way same against sold Clry
U Z in consequence of the groaning of this Permit.
�-^ APPLICANT U DERSTANDS AND WILL COMPLY WITH ALL NON-POINT Issued by: Date
SO CE
r 0
Re-roofs
S .tum o Applican Comracmr Oil
HAZARDOUS MATERIALS DISCLOSURE Type of Roof
Will the applicant or future Wilding occupant store or handle hvardous m.urial
as defined by the Cupertino Municipal Code,Chapter 9.13,and the H.Ith and Safety
Code,Section 25533(a)7 � All roofs shall be inspected prior to any roofing material being installed.
C Y.
opment or device which applicant os future Wilding on:.part esu cyIf a roof is installed without firs[obtaining an inspection,I agree to remove
Will doe
it harardnua air cmulnu an s u dc0ned by the Bay Area Air Quality Management all new materials for inspection.
oa s /'
❑Yes [7Nu
I have road the hvudra smateriaisuqumm ents under Chapter 6.95of du Califor.
nia Heul e:Safely Code,Sections 25515,25573 snd25534.1 unJcrnand thelifthe Wilding
Jos not currently have a mnonl that it is my respansihility to notify du Occupant of are
urorencnksw a xm ormi u Ora crdfiamarOccupeocy. SignatureofApplicant Date
Z; M l-�.3.1�� All roof coverings to be Class"B"or better
Clorer r authorized autho'zed aggeent Da¢