05110149 CITY OF CUPERTINO • - A:a'>«�zs:•wx
BUILDING DIVISION PERMIT , ,CONTRA.CfiOR INF:U ATION:..'
BUILDING ADDRESS: PERMIT NO0 5 110149.
ER.S NAME: PERMIT ISSUE DATE
JUDY LIN 12/22/2005
NE: SANITARY NO. CONTROL NO.
ARCHITEC(ENGINEER: BUILDING PERMIT INFO
BLDGO ELECT O PLUMB MECH
O O
�oo LICENSED CONTRACTOR'S DECLARATION Job Description
1 herehy affirm that 1 am Iittma
rved under provisn of Chapter 9(como
mencin6
with Section 70(11)of Division 3 of the 11"Mossand ProfesaionsCode.and my license is
in mumraandtma REVISION--RELOCATE KIT. & BEDRM,
i@z Cos
DaM CosCoA ADD CEILING BEAM. NO NEW PERMIT ISSUED,
rt Dam Gam DELL
ARCHITECTS W used
DECLARATION ORIG. #05070095
1 unticrmnJ my phos hall te uuJ u public rccnrd
t�
A tad
Licensed Professional
OWNER-BUILDER CXC PI T DECLARATION
ZOO
i hereby alarm on 1 1. exempt from lite CM11111001`8Cou License taw for the
is p o following resaon.(section RD I3,Bnsft esa and sae.dMmI Cmle:MY cloy at county
$ which requires•luanit to construes,alar,improve,demolish.or repair any suucwu
�y
prior it)I%issuance,also requires the applicant for such permil to Jilt a signed statement
<
that hchlicensed pursuant wthe provision ordue,ComeararauaroeLaw(Chapter 9 Sq. Ft. Floor Area Valuation
$ (commencing with section 7000)of Division 3 of the Businessumd Profmions Cook)or h0
that beca exempt therefrom and site Won for the alleged exemption.Any violation of 44
Section 7031.3 by arty applicant for a permit ubjecta the applicant Ira civil penally of APN Number Occupancy
not more than five hundred damn(SSW). P y�'Pe
❑I,As owner of the property,or my employees with mges u their tole compensation,
will do the work and the awchae h nm intended or offered for sale(Sec.7044,Business 37537065 . 88
and Profnsdans Cade:The Comuwr's Listen,Taw does oat apply an an owner of Required Inspections
props ny whobuilds orimprows thereon.and who dauuchworkhimselfarthrough his
man employees,provided thatsuch improvements are not intended oroffered for sale I.
however,0m Wilding or improvement is told within oro you of completion,the owner.
builder will haw site burden of proving that he did not build or improve for purpose of
sale.).
01.as owner of the property,w"elusively contracting with licensed commune;in
constmtt the project(Sec.70th.Business sed Professions Cade:)The,CmiractoYs V- .
cense law does not apply to an owner of pmpwy.who Wilds or improv themon,and,
who coconuts for such pmjecu wIm a contracwr(s)limned purwmt to the Contractor's
License Law.
❑i am exempt antler q= B k P C for this resat)
r r! �J'�^Y Dam 2 7_Z c
G ' O131 s COMPENSATI�ATION
I hereby affirm under penalty of perjury one of the following decham ou
1 haw am will maintain•Oentfmcem of Comoro in self-insure for Workefa Compete
sation,u provided for by Section 37M of the later Code.for the performance of the
work for which this permit is Iuuea
❑1 haw and will maintain Worker's Compematlon Inauruec,As required by Section
3700 of the later Code,for the performance of the work for which this permit is lamed.
My Workers Compensation Insurance canis and Policy number are:
Cartier. Policy No.: -
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(This section need two W completed Ifthe pamlit Is forms hundred doll.(SIM)
or mast)
1 certify that in the performance of the work for which this permit is Issued,I shall not
employ any person in trymuter pima tab t Workeri sadm
Compen .
Laws of California.GnarlL L�
Applicant !�%✓T'..+��r—�z
NOTICE TO APPLIC :If..after Makinig this CertiOeste of Exemption,you thould
Income subject to the Workers Compensation provisions of the Labor Code,you must
.J O forthwith comply with such provisions or this permit Nall W clamed rooked.
'Z 2 CONSTRUCTION LENDING AGENCY
�w
F Iter whichthi Ne Neuiaa issued
0tending agency for the perfurmaawe of
E
�,� site work for which this permit Is ivuccl(Sea 3097,Civ.CJ
aQ Leonine',Nam.
�z Lenders Adclresa .
U0 1-entry tint I hove tote this application and sou that ate stew turmoil.4
cortin.I ague to comply with All city and county aNinarnxs and now laws totaling to
O rU^ building construction.and hereby authmim representatives ofthis city to enter upon Ne
W show-AmmiM it pmpcny for inspection purposes.
(We)agree w on.indemnify and keep harmless the City of Cupertino against
m•a rA liabilities,judgments.costs ud,.pc=which may In try my accrue against said City
(„)7 in consequence of 0te granting of this permit.
Fl APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT Issued by: Dale
SOURCE REGyyLAApPTONS, //
lnf(A✓+ 175L�i L I✓t 1,zz_• r Re-roofs
Signatureof Applicant/Ca� Dam
HAZARDOUS MATERIALS DISCLOSURE Type of Roof
Will the applicant or future building occupant pore or handle h rrommus material
as deRmd by the Cupertino Municipal Code,Chapter 9,12.and the Ficalm and Safety
Sectiaa 255324)7
r]Yes ON. All roofs shall be inspected prior to any roofing material being installed.
W0 the applicant or future Wilding aauPanl uIa equipment or devices which .If a roof is installed without first obtaining an inspection,I agree to remove
I
hamdous air contaminar spa defiued by the Bay Area Air Quality Management all new materials for inspection.
requ
❑Yes ❑No
25505, 5533dingmlth u rent's yhava A omm,d 3505.2my rand23534.1ummuwm thulTtim Wildingnot curtontlY Inv•tenor,dal It h my responaihi111Y w notify tix occupant of the
tems w'h�`hh ustsormetp' rwiuuance,PfaCcntRcaloof piney. Signature of Applicant Date
I-LVL��LLy t !� �7 !!t
Owners a.IhMi1m1agent Dam All roof coverings to be Class"B"or better