05040072 CITY OF CUPERTINO
BUILDING DIVISION PERMIT t,CONT"CITORINVORMA.TION
BUILDING ADDRESS: PERMIT NO.
QUALITY WINDOW & DOOR 05040072
421 LANR;_DAT__R
OWNER'S NAME: FERMIT ISSUE DATE
E: SANITARY OL NO.
ARCHITEC rENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
0 0 0 0
app LICENSED CONntAC OWS DECLARATION Job Description
U 1 hcmby affirm that 1 am licensed under provision¢of Chapter 9(commencing
with Section 7") Lic.g
ofDivision" on 3 ofthe Business and Professions Code.and my licemc is
� N in fullforceaande eee
Licenu e REPLACE WINDOWS (6) /PATIO DOOR (1) &
7}�?
CZ ,, Dam Contractor2 WALL CUTDOWN TO MEET EGRES
r
ARCHITECTS DECLARATION
1 undersand my plata shall he used as public rtea,&
7yU
u Licensed Pnafcssianal
`era OWNER-exempt rmm the RATION .
Y 1 hereby affirm that 1 1. . from ilm ComnaroS License Law for the
a O fallowing mason.Permit
t ](131.5.Business,aien. and Pre,dcroli Calc:Any city stro nty
tur,
$v, which rtqusra n permit re cum,the aline,improve,demolish,or repair any stmetum
prior in its issuance.also mquims the applicant for such rector'toice s Law statement
< thathe mencing pursuamL )provisions of theContractor'sLiccnulaw(C Code)
Sq.F[.Floor Area Valua[o�029
'I–$ (cot M it;erg with hemfrom and the
basis
3 ch the Business and Professions Cak7 or
– that he u caroti IMmfrom and the baso for the alleged exemption.Any violation of
Section 7031.5 by arty applicam fora permit subjects the applicant no a civil penalty of APN Number Occupancy Type
not mom Nan five hundred dollars(5300).
1,as owner tithe property,or my employee;with wages as their sole compensation. 3 6911007 . 00
will do dm work and the swmme a nmimnded or offend formic(Sec.7841,Business
and Professions Calc:The Conoxmfs License Law does not apply to an owner of Required Inspections
property who buildsor impmwa thermn,and who docaamh work himselfor through his
own employees,provided but such improvements..or immndcd.,offered for We.If,
however,the building or improvement is sold within one year of compledon,the owner-
builder will have the burden of pmvmg that by did not build or improve for purpose of /1
01sale.,.
❑1,as owner of Jos property.am exclusively Contractingfesss with licensed commoners to
come,La theprojectnompply to an Business and Professions Cude:)Theves daemon,
nd (v
come law docs not apply to an owner of protons who builds of improve Comon.and. \V
who contacts for such projects with a contnaor(q licensed paracent w the COntndoh '\
License law. v
❑lam enempt under Sec. ,B&PCfor this reason
Owner Date
WORKER'S COMPENSATION DECLARATION
1 thereby affirm under penalty of perjury one,of the following declarations:
I have and will maintain aCer iricam of Consent to self-insum for Worker'aCompen-
amion,m provided for by Secfion 3700 of the Labor Code.for the performance of de
work for which this permit is issued.
❑ I have and will mainuin Worley/s Compensation Imuranm,is mquined by Section
3700 of the Labor Code,for the performance of the work for which this permit is issued.
My Workers Compensation Insurance carrier and Policy number am:
Cartier: Policy No.:
CERTIFICATE OF EXEMPTION FROM WORKERS
COMPENSATION INSURANCE
phis section need not WcomplcmJ if the pormil is foram hundred dollars(SIM)
or Ices,
1 cardiv that in(be performance of the work for which this Permit is issued.I shall not
employ any pCoMm in any manner ser as an become m1ecl to the Worker$Gompemadon
Lawsofcaliforom Dace
Applicant 'eA+�
NOTICE TO APPLICANT.after making this Certificate of Esemption,you should
become subject in Ne Wofkei s Compensation Provisions of the Law Cock.you raw
�z foMwithcomply with such provisions orthis Permit&hallxdeemed mvokcd.
ZO CONSTRUCTION LENDING AGENCY
14 I hereby aRrm that thyrt is a comvuctinn lending agency for the pm(urromm of
> No work fur which this tenon is issued(Sec.30TL Civ.C.)
tT]a lenders Name
Il. lender's Addmas
V O 1 certify,Nal 1 have mad this application and sane that the shove information is
F-' corrcn.1 agree to comply with all city and county oNhwmcs and sou laws muting to
Ons building construction,and hereby suthorim repremmauves of this city to enter upon Joe
Y'w above-mentioned property for inspection purposes.
(We)agree to save,indemnify and keep hnmeas ft City Of Cupertino against
liabilities,judgments,costs and expenses which may in any way we=against mid City
V z in consequence of the granting of this introit.
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NOWPOINT Issued by: Date
SOURCE REGULATI Ns,
Re-roofs
�
siSignatureof AppncanuConvacmr Data
HAZARDOUS MATERIALS DISCLOSURE Type of Roof
Will the applicant or future building occupant store or handle hetallous material
as dcbned by the Cupertino Municipal Code.Chapter 9.12.and the Health and Safety
cods.sem Yes es n532(a)7 t3Tu All roofs shall be inspected prior to any roofing material being installed.
❑
Will the ap,lmant or future building oceuput use cytopown,or devices which If a roof is installed without first obtaining an inspection,I agree to remove
it Itaurdnus air contaminants ss defined by the Bay Ate.Air Quality Management all new materials for inspection.
ixuict7
❑Yea QIP
I have matt the haratdous materials mquimments under Chapter 6.95 of the Califm- �—
nia Health&safety COM,Secdmm 25505.25533 and 2s53d.1 undersand thatifdm building �A J
does not currently have a mnanh Nat it is my MSFOMI hility m and I Joe occupant Of the
requiamenu wh m' x rocipdorwissuanaofa CcNRcao:O(Occupancy. _ SIgnd eof Applicant Date
!/ All roof coverings to be Class"B" or better
Owner or�iut r ved agent Dam