05070095 CITY OF CUPERTINO ',
BUILDING DIVISION PERMIT r�CU1VTRACT.O;RIN;E' RMATIUN,,
BUILDING ADDRESS: PERMYP NOO 5 0 7 0 0 9 5
OWNER'S NAME: PERMIT ISSUE DATE
JUDY LIN 10/19/2005
E: SANITARY NO. CONTROL NO.
ARCHITER/ENGINEER% BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
t� t�
30p LICENSED CONTRACTOR'S DECLARATION lob Description
u F I thereby Nm
reby affirm 1 am Ikxeme
d under provisions of Chapter 9 Memncing
`uf with Section 7M)of Division Sof the Businestand Pro(cuinm Code,and my license is
^ � mfullforcoandeOec, 9121ADDITION FAMILY .RM/2 BEDRM/1 BATH
Lkenw Class IY.w
Data Container 4381 GARAGE/REMODEL KITCHEN/MSTRBED/WINDOWS
,e ARCHffEC17S DECLARATION ROOF (800 ' )
y I undersau understand my plans shit M ted public mcnrds
� u
3 G� Licensed P.(..i...I
OWNER-BUILDER DECLARATION
BE I hereby Affirm Nal I Am exempt from the Contractor's License Law for the
E 0 O following mown.(Schon 703 1.5,Business And Professions Cade:Any city or county
$ which requires a permit In consu Ot,alter,Improve,demollm.or repair Any struauro
prior to its iuuarce,also mquUm theapplieant far such Permit to file a signed statement -
Fp< IhtheI.limn¢dpuatim,tothe provisions ofits.Conuecwe.U...Law(Chapter 9 Sq.Ft,Floor Area Valuation
3S (commencing with Section TODD)of Division 3 of the Bmmut And Professions Code)at $300799
Nis he exempt Uncertain and dte buts for Ne alleged exemption.Any violation of
Section 7031.5 by any applica ,for a permB subjects the applicant to a civil penalty of APN Number Occupancy Type
nm mom than five hundred Collar,(5500).
❑I,u owes.(the property or ay eaployw with wages u thebanle compensadon.
and dothework sod,-The
Continue.
etl OcaRercdtAct pplyA ABusiness
And Pro who builds
Cee:Th mthe em, ndwho law urns trot apply a an owner of Required Inspections
Own enywho basiproaImproves hImpr tedwho Coesouchwort himselfmthrough hu
however,the Wilding
orI Nu sveh(mprowmenuuenot year
orcded moQemtl for soleal,
however,the building or improvement b sold within one year a(mpro edon,the owner-
builtler will have the burden of proving that he did rot WW m improve fm purpose of
tele.).
i
Qmy5tat u ower of project
property.as Business
ray contracting with Ilaued rtmetaom e
=am a the es not (Sen.70th,Bwmeu And Proftrtywhoans Cob:)The Cmuamon, rad
ams law data not aPPIY to An owner o(propertYwha builds or improve Nermn,and,
who contracts for such projects with a eonuuto*)licensed puraum to the ConuAcofsAt
License m Law.
t0311
am teemp mineSee. .B$PCIreNismuaner �l U. � L i✓� DAu o WO ER'S COMPENSATION DECLARATION
1 hereby Aaa under penalty of perjury am of the following declunians:haw and will maintain A Cmincau of Cement a self-insum for Workers Compen.
n,as provided far by Section 3700 of the labor Code,for No perform...of Ne
for which Nis permit is luucd.
have and will maintain Workers Compensation issuance,u required by Saction
of the Labor Coda,for Ne performance err Ne work for which thio permit is inmd.orker's Compensation Insurance carrier and Policy number aa:
Cartier: Policy No.:
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(This scam need not Meomplcwd If the permit is forom hundred dollam($100)
or ksA)
1 canify that in the performance of the work for which Nie permit is Wom.I shall not
employ any perm In any mapmrso u e become subject a IM We C1 rmen�
4ws of C)ifomia.Dam 1 s V "1
Applicant — W sVN
NOnCE TO APPLICANT:If,aof making Nh Cenifiate of Exemption.you should
became subject as de Worker's Com usadon provisions of to Labe Cade,ym must
.J O foMwith comply wit such Provisions at Nis permlt shall W Maned revoked.
z D5CONSTRUCTION LENDING AGENCY
F Ihemby&Man Nat Nem Us conswcdon lending agency for Max performance of
LYi ti the work far which N4 permit Is Wood(Sm.3197,CN..C.)
Q Lender's Name
.7 z Lender's Addmas
U O 1«oily dust I hive mad Nb application And sum than the above infomadun Is
U,E torten.I agree to comply with all city and county ordinances and sum laws rclsting e
O building convection,and hereby authorice mpresentsdves of this city to enter upon the
127 shove-nmruMnW property for inspection purposes
G (We)agree to an.indemnify And keep harmless am City of Cupertino against
C.1 liabilities,judgments.emu and expenses which may in Any way Acme against mid City
U 7 in consequence of the Standing of this permit.
r� APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT Issued by: Date
SOURCSAUIa LATIc�S. r
I'\Lb/ ��i h Ie.l,°(. 05 Re-roofs c
Signatureof ApplkanVObnuimiar Dam
HAZARDOUS MATERIALS DISCLOSURE Type of Roof
Will the applicant or future building occupant nom or handle haamaaa material
As;defined by the Cupenma Municipal Code.Chapter 9.13,and Ne Health and Safety
Code,Section355)3()? All roofs shall be inspected prior to any roofing material being installed.
I]YAs ❑Na
W311 the Applicant or future building Occupant use equipment or devices which If a roof is installed without first obtaining an inspection,I agree to remove
,t hax d.. it mnmmmanu u deffned by the Bay Area Air Quality MAnageaem all new materials for inspection.
Distict7
❑Yea []No
I have read the hazardous materials requirements under Chapter 6.95.(Live Califor.
nu HealthBSaRIYCode,Swdm25505,25533a 2553a.1u re N i(tite building
data not curmely haw a mean,Nn it As my responsibility in notify,the=want of the
requiem ehm�lbe act Prior mums of a Canicula,ofoccuw�m // Signature of Applicant Date
—:P/% 1,P, IT I-1.0y
Owner ter anNomed age Date
All roof coverings to be Class "B"or better
L.