05020048 CITY OF CUPERTINO '
BUILDING DIVISION PER MIT T°RAC+fOn RIi�fl„t?RMATIQN
BUILDING ADDRESS: CHARLES SCHRAMM PERMITN 05020048
14 JAMES TOWN zR
OWNER'S NAME: PERMIT ISSUE DAZE
NE: SANITARY OL NO.
ARCHIIECTIFNGINEEW BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
LICENSED CONTRACTOR'S DECLARATION Job Description
F 1 hereby affirm that 1 un licensed under prevision of Chapter 9(cemmencing
n� with Section 7").f Division Sof ths Business road Profession Code,and my licence is
in full force and eRee. ADD 185 SQ. FT. (KITCHEN AREA)
n'n 3 License Clan Lie.a
C F Dam Comrectar
�p ARCHITECTS DECLARATION
�y`y9yu I understand my plans"I Im used a public mends
3
A ud�
Licensed Professionai
OWNER-BUILDER DECLARATION
1 hcmbyMaso.(Rte on 1 1. exempt from the C olons C'a :Any c Law for the
D p o following meson.(Section 71131.5,construct.airs"s and ve.de o li Cade:Any city tar county
$fLi which myuires a pemio to resdooaimg nt for
demolish,orrepaira sigAny structure
_ pdarmiuissumcc.also ensediumant to the d¢spplis,of the Contrach ctit or's
Utnmiaw(Ch ned comment
?� Nat hcisllttNsd purwentln the prevision of the ConuacurS Ucensa law(Chapter Sq.Ft. Floor Area Valu hon
€G (commencing with Section 7000)of Division 3 of the Business ad Profession Code)or
Nat M is exempt therefrom and the basis for the alleged exemption.My violation of
Section 7031.5 by airy applicant for a permit wbjecw the appliemt In a civil penalty of 3 6V1Vftftr0 0 Occupancy Type
not mare than five hundred dollars($SOD).
0 1,As owner of the property,or my employes with wag"As their sok compmsatlon,
will de the work,snd the structure lent intended oroffened Tarsale IS=7044,Bonn= Required Inspections
and Professions Cade:The Contractor's License Law don not apply m e an owner of q P
property who builds fir improves thereon,end whodoes s uch work himself fir through his
own employers,provided that ueh impmwmenu w not ImeMed aof(ered fornk.If.
however,the building or Improvement is cold within aro year of completion,the owner.
builder will law One burden of proving that Ise did cit build or improve far p.pan of
sale.).
5;rf.as owner of the property,am exclusively contracting with licensed come is to
contract use,project(Sec.7064.Business and Profwian Code:)The Conmem's U-
ceme law does not apply 0 an owner of property who Wilds or improver themon,red,
who conmcu for such projecu with a cantrxemr(0 licened pursuant to the Contractor's
License Law.
❑1 nml;empt under Se<. ,am P C far Nis noon
WOR SKCOMPENSATION DECLARATION
1 hereby affirm under penalty of perjury as of the following decmntioN:
0 I"..ad will maintain•CLrOncem of Consent to xeIf-Insure for WarkeYSCompen-
sation,as provided for by Section 37M of the labor Code,for the performance of the
work for which this permit Is Issued.
0 1 have and will maintain Worker's Compensation Insurance,As required by Section
3700 of the Labor Code.for the performance of the work for which this permit is issued.
My Worket's Compensation framance eerier end Policy number am:
Carrier. Policy No.:
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(This section need nothccomplcwd Ifthe Permit is fononhundowdoRaia(SIM)
or less.)
I cenify that in the perfomeaa of the work for which this Permit Is issued.I shall at
employ any peen in any mmgp^�u t tomsubjectto the Workers'CompenNan
Laws ofC o pp Dam
Applicant ' -- ^
NOTICE TO APPLICARnf.after making this Cenin"te of Exemption,you should
We=subject m the Workers Compensation provisional of the lata Cade.you most
Oforthwith comply with such provision or this permit shall W doemW revoked.
Z CONSTRUCTION LENDING AGENCY
[..t Ihereby affirm dui there is a construction lending agency for the performance of
IYs s7 the work for which this pemit Is issued(Sec.3097,Civ.C.)
W Q Leadce's Name
G Lenders Address
U 1 otenify that I have read this
Application and sum that the show Information Is
I.L corecL i agree at comply with all city and county ordinances and sum taws rcuGng to
building construction,and hereby authorise minamnutrves of this city to cmc upn the
Wshave-mammmed property fm Inspection purposes.
(We)AS.m taw,indemnify and lamp hamlesa the City of Cuper ins against
yItabtli0",judgemms,cosu andexpenses which may in my my scene,against said City
in C.I
APPLICANT DS A
eUN Uof dou NDERSTANDS AND WILL COMPLY WITH ALL NON-POINT Issued by:of this Permit. Date S
50 EGUL TI)fi�5. 5-4^0r
C�^vactor Y 7 Re-roofs
Signature of Appli"nAZARD oe Dale
HAZARDOUS Withal;
MATERIALSDISCLOSUREType of Roof
WIII the apCuped re future Municipal
Co occupant from 2.and t e Health
materiai
sa donned by tion Cupenin Municipal Code.Chapter 9.12.and the HWth arW Safety
Code,Sedon25532(.)+ All roofs shall be inspected prior to any roofing material being installed.
❑Y"
Will the applicant or Colors Wilding acupant are equipment or devices which If a IDOL is Installed without first obtaining an inspection,I agree to remove
mIt hozardnN air contaminants As defined by Ne Bay Area Air Quality Management all new materials for inspection.
District?
Dyes L3fiu
I haw mad the haraNwsmuerialsecquimmenu under Chapter6,95 ofthe Califor. O
nu Haiti"SafetyCode,Sections 25505,25533 And 25534.1 understand thatifthe Wilding ,J ^��
dos ryryyy cumnI hew•=.4that Itumyms D.ibilitymnotifydeseecupmtofties
myuNerknu whim y4q mm priarw urumm of a Cenifmam of Occupancy, Signature of Applicant Date
//111111//""AAL 1/=�.1— .J r'f{sd�
Owner tar authorized agent Date All roof coverings to be Class"B"or better
G