06050234CITY OF CUPERTINO
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BUILDING DIVISION PERMIT
..CON,TRA.GTOii"IIYRMAT7,Q1
BUILDINGADDRESS:
WALTER VAN HOOF & MIKE CHE
trRMINO'06050234
10066 JUDY AV
ER's NAME:
PERMIT OUR DATE
WALTER VAN HOOF & MIKE CHE
PHONE:
SANITARY NO. CONTROL NO.
ARCHITECT/ENGINEER:
BUILDING PERMIT INFO
BLDO ELECT PLUMB MECH
l 3 O O D
LICENSED CONTRACTOR'S DECLARATION
Job DCSCflphOn
1Wmby0)of Nall emfthe licensed Chmia (commencing
with Suction70110)of Division Jofthanominee and Professions Code,andco
Business is
in roti forte and effem
DEMO 1 STORY SFDWL
FIN�� EU
License Clus Lic. g
Dam Contractor
ARCHrMCI-S DECLARATION
I understand my plans shall he used u public meords
JUL V
t� I L /'0• tI 2006
Licensed Professional
OWNER-BUILDER DECLARATION
I homey aRrm that I am eaempl from the Contractors License law for Me
fallowing moon. (Section 703 1.5, Business and Prefcasiam Cade: Any city or county
which squires a Footnote construct. alter, improve. demNim, or minor any Serunum
prior to its issuance, alto requites Me applicant forseth permit to ftu a signal suemanl
Contractor's Liccnsc Law 9
Sq. Ft. Floor Area
Valuation
that he is licensed recommit, the provisions of the (Chapter
(commenting with Section 7000) of Division 3 alum nostrums and Fmieeuions Code) or
that he is commit thesfrom and the bub fa the alleged exemption. My violation of
Occupancy Type
Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of
nut mom Ilan five hundred dollars, (M).
❑ L u owner of thc pmpeny, or my employees with weges u theirele compensation,
Required Inspections
wNdo thewaak, Tani 70 m4. count
der
Coda: Tim Catheters Lkwe Law lou Out apply tf rt owner
obrew Lodedm Lawapply.
and Cods: an Commences
q P
is
pcepenywha Wiprovid ceprew Msmprove who damsuchwark himsel(or through his
property wh build,
Nowakimprowd far eh.Ir.
awnemployees, ping
witamanyear cma0emd
however. the Or ellwithinoroyear ofcompletion,the owner-
ame th{wImprowmantIt
win Nve the Wrden of proving dot he did rot boob or improv for purpose of
sam.)Wittier
sam.I.
❑ 1, u atom, of she property, am exclusively cmuu0n{ with licensed camuscmrs to
coestrom the project (Sec. 7044. Business; me Professions Code:) The Contractors Li -
come Law ducks not apply to an owner of property who Wilds or improv dmsm, and,
who contracts for such projects with a canuumrts) licensed pumuml to the Contretart
License Law.
❑ Iamaemptunese See ,B&PCrMMismuon
Data
WORKER'S COMPENSATION DECLARATION
I hereby air= under penalty of perjury oa of gte following declarations
❑ I haw and will maintain a Certificate of Consent to el( -Inure fa Workers Coopen-
sadm, u provided for by Section 3700 or got labor Code, fm the No-- of Me
weak for which this permit is issued.
I have and will maintain Workers Compensation resonance. u squired by Section
3700 of Ne Labor Code. for the performance of the work for which this permit is issued.
'
My Workers Compensatian Insurance carrier and Policy number am:
Cartier, Policy No.:
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(Thisseedon anti mtheeample rad ifft permit Is farm hundsddollan (SIM)
M, lam)
1 ocmfv Met in Ne pa(ormance of the work for which this pemdt is issued. l Mail per
employ any person in my manmre as an become subject to Me Workcri Compensation
Laws of California. Dam
Applicant
NOTICE TO APPUCANT. If, after making this CeelOeate of Exemption, you should
become subject m the Workers Campenser on provisions of the labor Cada. you mtm
forthwith comply with such provisions or the permit shall W demmN mwked.
UCITONLENDING AGENCY
mau ft. agcay far the pMormamx N
thereby eshy LM. dot them 41
ed (Sm 30 7, Cing
the work (tar which N4 permit b isucd (Sac. 31191, CN. CJ
'
LeMName
fendees M1Addm•-
i 1 certify that I have mad this application and some, that Ne show information b
' carred. l apse to comply with all city and county commences and sum laws slating 0
building construction, and hereby authorim representatives of this city to enter upon the
above-mentioned property for inspection pugesem
.
(We) agree to eve, indemnify and kap harmless, Me City of Copmtira against
liabilities,judgments, costs and eapemm which may in any way tame agaimt said City
in CcnWga.ce of gte {ranting of this Permb
' APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON -POINT
Issued by; Date
SOURCE REGULATIONS,
Re -roofs
Type Roof
Slgnuuen ofApplicmUConsrutor Dam
HAZARDOUS MATERIALS DISCLOSURE
of
Will the applicant or future Wilding ampmtnare or handle hammous material
u denad by tite Cupertino Municipal Cade, Chapter 9,13, usd Me Health and Safety
scene. 35533()7
All roofs shall be inspected prior to any roofing material being installed.
❑Yon [3 No
If a roof is in without first obtaining an inspection, I agree to remove
Will the applicant or future Wilding occupant use equipment or devices which
emit hmakaw air contaminants as defmd by the Bay Area Air Quality Management
all new materials for inspection.
Dimmt7
❑Yes ONO
I have mad the huardatts com sin mquimmmm ulakr Chapter 6.95 of Me Callon-
alifonria
M4Hull &SefctyCodc, Sections 35505,35533 and 75534.1 tmMrstood dm ifthc building
does not currently have a tenant Met it b my responsibility to mdfy ge occupant of the
mquimments which most be met prior to isnomm of a Certificate of Occupancy,
Signature of Applicant Date
All roof coverings to be Class "B" or better
"
Owner or authorised agent Dam