05040027 CI'T'Y OI,'CUPERTINOix «+ ,t�-"r�.
BUILDING DIVISION PERMIT CON, 'CT,RAMP ,, ATION ,'s.
BUILDING ADDRESS: RICHARD MADEN PERMITN0.O5O4OO27
OWNTMPERIA1,I A-V
ER'S NAME: PERMIT ISSUEDATE
,JE: SANITARY OLNO.
ARCHITEC(ENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
0 0 0 0
�00 LICENSED CONTRACTOR'S DECLARATION Job Descri tion
U F 1 hereby African that 1 am licensed under provisions of Chapter 9(commencing P
^�`�' widh Seclion7dXk0 of DivixionJofplc¢usirexs and Professions Cox.and myliccnse is
d Lfunfnae and cffen.
Z-� License ClBu Cm
du REVISION--PHOT. SYSTEM ON ROOF TOP
—D Data TS DE L NO NEW PERMIT ISSUED/ORIG. 4 03110121
�'J` ARCHITECTS DECLARATION
UIandemandmyplans&hallbcused aspublic records CONTRACTOR: STEVE ANDERSON CONST. CO.
O
t; Licensed Profcssinnal
S ffiOWNER-BUILDER DECLARATION
j 1 Wichy arm m that 1 aexempt from Bre CnramaY
nls Lieemm law for the
ya O0 following reason.(Section 7031.5,Business and Professions Code:Any city rat county
%m which 2qulles a Permit In remainder,aIle,Improve,demolish,or repair any dr cWre
a1 prier In its Issuance,sloe millibar be applicant for such Permit to file a signed statement
that he is licensed pursuant to the provisions of the Contractors License Law(Chapter 9 Sq.Ft.Floor Area Valuation
`4 (commencing with Section 7000)of Division 3 nfthe Business and Professions Code)or
..
that he is exempt Neafrom and die buis for the alleged exemption.Any violation or
Section 7071.5 by any applicant for s permit anbjecta the Applicant to A civil Penalty of APN Numbere NCtecupaney Type
not mane Bve hundred dollars(SSI,).
❑1,As owner of the j mpeny,at my employees with wages u their sole compensation,
will do the Week,and Be&wcmle Isnot intended or offered formula(Sec.7044,Busircu 35717017 . OO
Add ProiomfcssCox:The Count License law doer not apply to an owner of Required Inspectiory� r
property who builds or improves thereon.and who docs such work himself of though his V
n employees,provided that such improvements uo ned intaMed oroOUW 0,ale.,. \
builder,the buil the burden
of proem issat heiiinot Wild
ofmorro forun,theowrmr
builder will M1ave dhe burden of proving that be did nn build or improve for Purpose of J
sale.).
El 1,as owner of the property,am exclusively contracting with licensed contractors to
worm et rhe projret(Sec.7044,Business and Professions Cade)The Contractor's U
emu Law does not apply in an owner of property who builds or improves Iheteen,an0
who comracu for such projects with s mnmcmrbs)licensed pursuant to the ConBaaors
License Law.
❑1 am exempt under Sec. .B 6 P C for this osson
Owner Data
WORKER'S COMPENSATION DECLARATION
1 hereby affirm under Penalty of perjury one Of the following declarations:
1 have and will maintain a CertiBcam of Consent to self-insurt for Warlock's Cooper-
As proNxd for by Section 37W of the labor Cash,far the Pcrformance of Ire
work for which this permit is issued.
❑1 ban and will maintain Worker's Compensation Immanuel u required by Section
37M of the Labor Code.for the performance of the work for which this comic is issued. -
My Worker's Compensation Insurance tastier and Policy number are:
Carrier Polity N.,
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
('ITIS section need not Mcompleded if the permit is fortune hundred dnllims($HXB
or less.)
1 certify that in the performance of the work for which this permit Is bssucd,1 shall not
employ any person in any mannerso u to become subject to the Workers'Cmnpenstarm
Laws or CoLlornis.Date
Applicant
NOTICE TO APPLICANT.IL after making this Ceni0ca a of Exemption,you should
become$Object to the Worker'&Compensation provisions of the Lehr Code,you musk
.UO forthwith comply with such previsions or this Fermi Ishall W deemed revoked.
Z CONSTRUCTION LENDING AGENCY
[-r .N. I hereby affirm that there is a construction lending agency for Performance of
W? the work fur which this Permit Is issued(Sec.ING,Civ.C.)
WQ Lender's Name
M.,z Under's Address
U 1 rectify that 1 have read this Application and state that the above information is
W H coved.1 agree 10 comply with all city and county ordinances and sure laws relating to
0U building Crosami and hereby Ardmore reposenlntivea of this city to enter upon be
1 shove-mentioned property for inspection PurFo¢s.
(We)agree to save,indemnity and keep harmless the City of CupeNno sgairut
liabililies,judgmens.ensu and expenses which may In any way secmc against said Cory
U in consequence of the granting of this permit.
.. APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT Issued by: Date
SOURCE REGULATIONS.
Re-roofs
sisn,wke mAFphd.HAZARDO Date
HAZARDOUS b MATERIALS DISCLOSURE Type of Roof
Will plc a Cupenl or Town building ........re r 9.1 or mantic Notorious...coalSafety
u defined by the Cupertino Municipal Cade.Chapter 9.12.and the IldehM1 and Safety
Cudc,Schon 35331(a)1 All roofs shall be inspected prior to an roofing material beim Installed.
❑Yds No P P Y g g
Will the aPplicw or for..building occupant um equipment or devices which If a roof is installed without first obtaining an inspection,I agree to remove
-nth ha nous air contaminants u&fined by the Bay Arca Air Quality Management all new materials for inspection.
Diok7
❑Yes No
1 have read the havnNws materials requhe arms unxr Chapter 6.15 of the Califor-
nia Health S Safe,Carlo,Sections 25515.25533 and 25534.1 un knund thud if Ne Wilding
does not currently hove a lenem,Nal it is my responsihddy It unary the aeupant of Ne
requirements which mum he mel pour to issuance of a Cerebrate of Occupancy. Signature of Applicant Date
Owneor mmedved agem Date All roof coverings to be Class"B"or better
CI'T'Y OI'CUPXR'1'INO
BUILDING DIVISION PT✓RMIT s�CON,ut k TOR INk'ORMATION,
BUILDING ADDRESS: PERMIT NO.
05040027
is5 PERMIT MUE DATE
aE:RICHARD MADEN SANITARY j24OL NO.
ARCI3ITECDENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MF.CH
0 0 0 0
yOp LICENSED CONTRACTOR'S DECLARATION
u F '1 M¢by affirm that I am lian¢d under provisions of Chap.,9(commencing Job Description
ZZ`af with Section YON))of Division 3 of Nc Business and PnfcssinnUiode,end my license is
71 in full force andr¢ L
3l2 Lice nmCI � Lic,A Ya REVISION- -PHOT. SYSTEM ON ROOF TOP
Date /5 1 Conmco .YN
QQ7W ARCIIITECPSDECLARATION NO NEW PERMIT ISSUED/ORIG. # 03110121
I understand my plans shall W used u public records
U. Licensed Professional
OWNER-11U TO from
DECLARATION
MS 1 hereby affirm that I em eacmpl from me Cmm�noh License Law for the Q
i O O following reason.(Section 7031.5,Business and Professions Cade:Any city fir county f
$ which requires a permit to eonNpct.alter,improve,demolish,fir.,.it any mucutre
FZs
poor is its irsnance,also requires the applicant ser such pctmi In file a signed statement
xx that he is licensed pursuant to the provisions of the Contractor's License Law(Chapter 9 Sq.Fl. Floor Area \ Valuatiop000
yF� (commencing with Section 7")of Division 3 of the Business and Professions Count or $.S
BOB he is exempt therefrom and the basis for the alleged exemption.Any violation of
Section 3031,5 by any applicant for a permit subjects the applicant to•civil penalty of APN Number Occupancy Type
nm am than five hundred della.(S50y.
0 1,as be,of the propcoy,or my employees with wages As their to compensathm.
will do the work,and the structure is not intended or offered for site(Sec.30aa,Business Required Inspections
and Professions Code:The Contractor's License Law does not apply m an owner Of q P
property who builds or improves thereon,and who does such work himself or through his
own employees,provided that such improvements am nm intended or onercd for ale.IL
hmvever,the building or improvement Is sold within one year of completion,the owner
builder will have the burden of proving that he did not build or improve for propose of
ale.).
0 1,as owner of the property,am exclusively contracting with licensed contractors to
construct he project(Sec.7044.Business and Protestors Cade:)The Conuactor's Li.
ccme law docs not apply to an owner of property who Wilds or improves thereon,and
who convects for such projects with a contractor(s)licensed pursuant to the Contractors
License law.
O l am exempt under Sec. ,B h P C far this reason
Owner Data
WORKER'S COMPENSATION DECLARATION
1 hereby afron under penalty of perjury one of the following declarations:
Ave and will maintain a Ceniftcem of Consent o self-insure for Worker's Crimper.
on,u provided for by Section 37M of On LAW,Code,for Are pent..m.of the
work for which Nis permit is issued.
1 have end will maintain Worker's Compensation Insurance,as required by Section
"par.
300 of IW Ia Wr Coat,for me pedormmce of the work ire which this permit ix issued.
My Worker's Compensation Insurance carrier and Policy number are:
Carom Policy No.:
CERTIFICATE OF ER EM MON FROM WORKERS'
COMPENSATION INSURANCE
(This section need not be completed Rthe Permit Is foronc hundred dollars($100)
city
I ecnify Nat in the pc,farm ance of lite work for which this peUait isissued,I atoll not
employ any person in any Too u�h Llalhc workers'Compensation
Laws of California.Date Jia" / W
Applicant
NOTICE TO APPLICANT:IL after making this CeriHcam of Exemption,you should
become subject to tax Worker's Compensation provisions of the V Wr Code.you most
�O fo.hwith Comply with such pmmi...of this Permit hall be deemed revoked.
Z CONSTRUCTION LENDING AGENCY
�-. I hereby affirm Our them is a eonswction lending agency for the performance of -
a 7 the work fur which this permit Is issued sec.3097,Civ.C.)
W 0 Undeis Name
z Under,Add..
U C I Bendy that I have.ad this application and axle than the above Information is
^F meet.I agree to Comply with all city and County ordinances and sum laws misting to
OU building construction,and hereby aalofln marcatmadws of this city to enter upon the
r W abovcmemioand property for inspection purposes.
C (We)agree to save,indemnify and keep hafmless the City tar Cupertino against
tifq liabilillea,fudgmcnts,casts and....Uses which may in anyway accrue against said City
U Z APPLICA nc NDe graTAN SthisD WI. MPLY WITH ALL NON-POINT Issued by: Date
SOURCE U T NS
Re-roofs
Signs
ibrfrof Ap anrconlnemr Data
HAZARDOUS MATERIALS DISCLOSURE Type of Roof
Will Ne apli icanmr future building occupant store or handle haaardous material
as defined by lie Cupertino Municipal Cade,Chapter 9.13,and the health and Safely
Chile.secdenas3x(o7 All roofs shall be inspected prior to an roofing material bei. installed.
❑ver 0No P P Y g g
Will the applicant or future building occupant use equipment lir devices which If a roof is installed without first obtaining an inspection,I agree to remove
hazamous air contaminants as defined by the Bay Area Air Quality Management all new materials for inspection.
7d�,
icht
❑Yes ON.
1 have Ictal the havardtws malmialsmquimmcnts unhkr Chapterli.95 ofthe Califor-
ealthKSafchendle,Scent 2550$,755]1 , undemam m.ifte Wilding
nenil coca tism9rr yres bilittyymnndlylWrecupamofree
ire. ks ma n at Mot to issuance of acatficateofOccupancy. Signature of Applicant Date
oraulhoriacd.,cut Dam All roof coverings to be Class "B"or better
CITY OF CUPERTINO
I� 1 of 1 PERMIT RECEIPT OPERATOR: conniew
COPY # 3
Sec : Twp : Rng: Sub: Blk: Lot :
APN . . . . . . . . : 35717017 . 00
DATE ISSUED. . . . . . . : 04/21/2005
RECEIPT 4 . . . . . . . . . : 29404
REFERENCE ID # . . . : 05040027
SITE ADDRESS . . . . . : 10101 IMPERIAL AV
SUBDIVISION . . . . . .
CITY . . . . . . . . . . . . . : CUPERTINO
IMPACT AREA . . . . . .
OWNER . . . . . . . . . . . . : RICHARD MADEN
ADDRESS . . . . . . . . . . :
CITY/STATE/ZIP . . . : CUPERTINO CA, 95014-5906
RECEIVED FROM . . . .
CONTRACTOR . . . . . . . : LIC #
COMPANY . . . . . . . . . . :
ADDRESS . . . . . . . . . . :
CITY/STATE/ZIP . . . . ,
TELEPHONE .
E ID UNIT QUANTITY AMOUNT PD-TO-DT THIS REC NEW BAL
------- - - - -------- - - - ----- ---------- - ---------
BPLANCKREP HOURS 2 . 00 174 . 28 87 . 14 87 . 14 0 . 00
BUSLIC FLAT RATE 1 . 00 102 . 00 0 . 00 102 . 00 0 . 00
---------- - - - ------- --------- - ----------
TOTAL PERMIT 276 . 28 87 . 14 189 . 14 0 . 00
METHOD OF PAYMENT AMOUNT NUMBER
--------------- - - ------------ ---------- - - - - - ---
OTHER 189 . 14 VISA
TOTAL RECEIPT 189 . 14