08070146 CITY OF CUPERTINO 'b* +�wi r•�yesry.: a<a�y£ �s� ""- ` % ' '�':
BUILDING DIVISION
PERMIT
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BUILDING ADDRESS: PERMIT NO.
1.0321 JOHNSON AVE JJJ CONSTRUCTION 08070146
NER'S NAME: PERMIT 65IIE DATE
J1AY:I: LI 606 HAMILTON AVE 08/07/2008
PHONE: SANITARY NO. CONTROL NO.
(650) 322-1275
ARCHITEC17FI4GINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
0 0 0 0
�O p LICENSED CONTRACTOR'S DECLARATION JOb Description
1 barely affirm that 1 w IisrcM under Provisions of Chapter 9(comDSCrIP
mencing
with Sacdan 70004 ofDivWon 3 of the Business and Profession Code,amd my license is TRUSS CALCS — ORIG $08030177
n in full force,nd affect. G$ q21 3
Lbam Ctau fY.R O
MF, Dam Contractor
ARCHITECTSDECIARA I N
I untlersanJ my plans shall W used u puhlf&reenNs
JyU
g C Licensed Pmfessbna
ca3 OWNER-BUILDER DECLARATION
C<7 hereby akso a1Rrm on 1 am xempt from be Comm�e,Co :kenceAny c Law for be
COO o following muga(Section ftD mo Business and ow.dcara Cafe:Any city or county
whic0. mquirus a issuance.croalso
W comaxial.
th L aha,improv,h Permit
er W,ore a.ir any rectum
Priorbiuensednfientnthe rW apions ofcant for achpctoi's OleasiamasuWma,
s< wnlminratnea p°ecu.ntbwa of of am cnBlracbrsu«n�ssW(Chapter Code) Sq.FL Floor Area Valuation
X52 F$ (cam a Is(commencing exempt
Sectionm and the
un 3far of dim adle inert and on.Any vio don or $0
yo�
that io is exempt BWmfmm and be lull for the cls the exemption.to Any violdan of
Section than
five
any applicant for•permit subjects the appBcsnuo a civil penalty of Number Occupancy Type
not more bis five hundrt0 dollua(g500). 3751803 5 �(� P Y YP
❑I,ss ownar of the pmperry,army 5mployen with wage u aWirmle compenaaon,
and Pithework Cade,-
nnisme,Lt oar oRe dost mal apply in.Bus•.of
and enywhoru Calc The ContrxbYs Lima law don mat apply lf rt awrcr is Required Inspections
pme enywM Wildaered that
improvements
meet chwork himselfor Wr We his
employes,pmgor i aper Amb Imprewmas art not intendedfe urartnmd the owner.
Witmer
Witmerhowever.the Wilding or impmvmanl is sold within one yen of completion,the owner
sae.). will love the Writers of proving that W tlltl not Bala or improve for purpose of
sale.).
0 1.as ewrcr of the preparsy,am exclusively awrncting with licensed contaminant W
co=uact the project(Sec.1044.Buinm and Professors Cotler)The Contractor's W .
cense law dora not apply to an owner of property who Wilds ar improwa Berton,and
who contras fm such projects Mth a commea r(s)licensed Pursuant to the Commences
License Law.
O lemeaecatradem See ,B&PCf=thareaan
nu
Data
WORKER'S COMPENSATION DECLARATION
1 hereby alum under penally of perjury arc of be following decimations.
I ham and will maintain a Cerafieam ofConsont W self-Worm forworkees Compen-
/an.a provided for by Section 3700 of be Labor Cade,f=be performance of the
wart for which this permit is issued.
0 1 haw mad will maintain Worker's Compensation Inmmence,as required by Section
37W of be Labor Code.for the performance of the work for which this pemitis issued. '
My Warkees Compensation Iwranse carrier and Policy number ase:
Cartier: Policy No.:
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(TIds sectim reed rot W cenplemtl ale permit is franc huMmddollas($100)
or leu)
I certify that in be performance of the work for which this scall is heated.l shall not
employ any perm=. any manrcrmu W Wame mbjalaetho Worken'Compeuarlon
U� 'of CsifomiilDam ..G,
NCDC nl C ni lei
NOTICE TO A ANT:a.after Commaking pr CeniOnW m Exemption,you should
become romp y the Worker's Compcuktion provisions of be labor Ceded you mass
.J O forthwith comply with such prerisioa or this permit stall W aamca revokeQ
Z� CONSTRUCTION LENDING AGENCY
[—� I homey allrm that Vert is a coauuetion lending agency far the performance of
lX the work for which bis permit is issued(Sou 3097,Civ,C.)
4 Lande's Name r
z Leader's Addm..
V Q I coolly the,I have read this applicaon and sus that are abow infamadm Is
!'. camcL 1&gra as comply with a1 city and cowry ardinanca and stare laws misting W
Q SV' Wilding construction.and hereby authorise representatives of bh city W cam,upon be
[n
above-mationnoms.cst for inspection purposes
(we)agree to saw.indemnify and kaP l atalns the City of Cupenina agaut
ti Z incoisequen consequence
fin&expeun which may In any wy&amc oats,said City
(„) 'z in asequence of am granting of this permit `
APPLIC Nr UNDERSTANDS AND WILT.Cp�sPLY WITH ALL NON-POINT Issued by:9 Date !Gi
SOUR REGUAC.N: //1 I
S �I//��Fc, V/1� rod Re-roofs
Slge roof Appls=nUConmacWr Data
HA]ARDOUS MATERIALS DISCLOSURE Type of Roof
Will the applicur,=future Miele,otepanlsbrt or handle hoardon mamrid
u defined by the Cupeeina Municipal Cade,Chapter 9.12,and tW Hnith and Safety
.sectiamus3z(gl All roofs shall be inspected nor to an roofing material beim
❑ver Na P P Y g g installed.
Will be applicant or future Wilding occupant use components or @vias which If a roof is installed without first obtaining an inspection,I agree to remove
emit haadm=air cumaminans as dclircd by the Bay Asea Air Quality Management all new materials for inspection.
Disal
Dy. (dtvo
1 have red the inseminate mamriah requirements under Chapter 6.95 ufthe Califm.
nh H=I &Safety Cattle,Section 25505,25533 and 75534.1 underwand bis if am Wilding
dura rte cu Sa et law&Wrpen4 that,It h my rapeaslility W Mary am occupant of am
�1/11
` ° jW W am oy'c" m'W°q M �, SignatureofApplicant Date
owner or aubadred agent cf Dam All roof coverings to be Class';W'or better