04060096 CITY OF CUPERTINO ''!
BUILDING DIVISION PERMIT ` CONTRACTOR INFORMATION �y�.:'
BUILDING ADDRESS: PERMIT NO.
MARTHA K71NG 04060096
30143 IRRANON
OWNER'S NAME: PERMIT ISSUE DATE
MI— MAPTWA XAMn 1"'5"
E; SANITARY 0 OL NO.
ARCHITECIENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
0 0 0 0
Lap LICENSED CONTRACTOR'S DECLARATION
F❑ 1 battery affirm that I am littnscd und�erP visions of chapter 9 o ommencmg Job Description
<W with Se.ian7000)Of Division3ofine Boa'A4nd Prafexsium Code.and my licenmu
intoBr.e ana err«t. ✓ �3 �j,��/Z.{ NEW 2-STORY SFDW (3920 SQ. FT. -LIVING SPACE)
.I2 Z License I s t Lite.at
° Contrac.r �Ln��lt '/GARAGE 651 SQ. FT.
ARCHnEComd`x; l�h1,9�ON
K I undcruand my plans II he used u pu�RCID�rth
tau cs
iotH Licensed Pm -m
5 O an C ARAmcN
1 hereby aUirm mal I em cxc pt rrvm Contrnaafs License Lew for me
°O fallowing moon.(Section 7101.5,Bus Pmfesainns Code:Any city or county
m which legatees a permit m CO.".alter,improve,demolish,or.pair any structure
poor m its issuance,also requires the applicant forsuch permit to file a signed statement
?< that he is licensed pursuantto the pmvisiom of the Contracwri License law(Chapter 9 Sq. Ft. Floor Area as Val8 3F]a OOO
Ems° (commencing with Section 70XB of Division 3 of me Business and professions Cale)or ` ti} 7
a $
that he is exempt thertlmm and the buffs for the alleged exemption.Any violation of
Section 7031.5 by any applicant for a permit ubjects the applicant to a civil penalty of ApN Number - � Occupancy Type
not mom man five hundred dollar(5500). -
❑Laawnv♦rove pmpcny,or my employe♦wim wageses thctrsole compensation, 34214005 . 00
willdothewok.andmesw.u.isnotimmndcdorORet fontle(S=.7 M.Buvnw v vf' ;It
and Professions Cade:The Commic.fs License Law does not apply to an owner of Required Inspections♦p
property who builds or improves thereon,and who does such work himself or through his
own employes,provided that such improvements art not intended oraRemd for sale.If,
however,the building or improvement is sold within one year ofcompledon.Inc owner-
builder will bare da burden of proving that he did rot build or improve for purpose of
.Is).
❑1,as Owner of the property.am exclusively contracting with licensed contractors to
construct the project(Sec.70m.Business and Professions Code:)no Contractees Li
cense law dues not apply to an owner of property who Wilds or irnproves thereon,and
who contracts for such projects with acontrate.Ks)licensed permans.the Contractors
License law.
I am exempt antler See .B h P C far this reason
Owner Data
WORKER'S COMPENSATION DECLARATION
1 M.by affirm under penalty of perjury ane of the following declarations:
Iran and will maintain a Certificate of Contin to self-insure for Worker's Cote en
.ion,ss provided far by Section 3700 of the Laror Code,for the performance of the
work for which this permit is issued.
❑1 ban and will maintain Worker's Compensation Insurance,as required by Section
3700.1'the Labor Curie.far the performance Of the wok for which this patron is ismad.
My Workers
�Compensation
y ompetuauoJl. 1^n (♦fetter and Poljry number ac�3�
C12J. //aSC o'er/ya.: /5.7
CERTIFICATE OF EKEMFD0N FROM WORKERS'
COMPENSATION INSURANCE
(Thu rection heed not he completed if tic permit is for ane hundred dollars(SIM)
less.)
I certify that in the performance of the work far which this permit is issued,l shall at
employ any penin in any mannerso a to become subjec0a the Workers'Compensation
Lawa of California.Date
Applicant
NOTICE TO APPLICANT:If.after making this Ccnificate of Exemption,you should
become subject to the Workers Compensation provisions of the Lahr Codc,you must
.J O forthwith comply with such provisions or this permit shall W demand revoked.
z "-' CONSTRUCTION LENDING AGENCY
(~ I hcmbyaflirm that there iso construction lending agcmy far the perfursomm u!
!� that work for which this permit is issued(Stec.3097,CO,C.)
11.1 0 Landcr's Namc
= z Lender's Address
V C I certify mat I ban read this application and mote tha the♦bon infannumm is
W P correct.I agree to comply with all city and county of inanes and mute laws mlating to
p V building construction.and hereby authonse rtprerenuttves of this city to enter upon the
r W above mentioned property for impound purposes.
(Wer)agae to San,indemnify and keep bootless the City of Cupertino against
au s
F h habilidex,judgmmnts.condcxpenses an
which may in y wayacctuc agamthand City /
V Z in consequence of the granting of this permit.
^ AP ICANT UNDERSTANDS AND WILL COMP61=WFjH ALL NON-POINT Issued by: Date
I{v
80t7CE REGUNS. \//
zali Re-roofs
Sigmtoi pplic .r a¢
RDD S MATERIALS DISCLOSURE Type of Roof
Will the applic ratio rte building occupant State or handle livardous material
tn�
cd by the Cup: ,ni,ipal Cade.Chaps 9.11.and the Hcalm and Safety
CoderiYes zss3xan 'P
e All roofs shall be inspected prior to any roofing material being installed.
Will thea applicant or(mart building Occupant use equipment or devices which If a roof is installed without first obtaining an inspection,I agree to remove
pp g p Area
n
hazardous air contaminants u JcfncO by tine Bay Arta Air Quality Management all new materials for inspection.
❑Yes1 have raid the hicordaamposcluls.quiremenu ua&,Chapter 6.95 ofthe Colifor-
thSSafcryCode,Sections 15505.25533 and 15534.I unicrsuntl that ifthe Wilding
t curtently ran a¢rant,Nat it u my respoesihility.nodi the oeupant nr themenu which mina- met pdorm is uancc ora CCNbcate of an .
Signature of Applicant Date i /
owner a ttze t Da All roof coverings to be Class"B" or better' C/