05030005 CITY OF CUPERTINO k �n.«ya,^ K ne �} ,(`�"y�k,{yi OU,
BUILDING
BUILDING DIVISION PERMIT1F.�' 1�1Y1 �1\
BUILDING ADDRESS: PERMITN0050300 05
1 (14,10 T-TUDGAM All
OWNER'S NAME; PERMIT ISSUE DATE
E; SANITARY0. CONTROL NO.
ARCHITECTIENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
0 0 0 0
30o LICENSED CONTRACTOR'S DECLARATION JbDescri tion
I Macley aflh,n that I w op
licensed under provisions of Chapter 9(commencing
with Section 7")of Division 3 of the Business and Professions Code,and my license is
a infull maandercea ADDITION 748 ' /REMODEL
cClClew Lk.g
�gZ License'
Does—Contractor FAMILY RM/MSTRBED/BATH/GAME Rtz4��
ARCHITECT'S DECLARATION I.L
1 understand my plant shall he used u Ppublicrrecords;5illC/afeD
h^a
O OWNER-BUILDER DECLARATION
i�3 Licensed Pro@ssiond ®
1 hereby arcbm Net I em eacmpt from the Conus ctufs License law for the y^/w�
O O following mason.(Section 7001.5,Business and Professions Code:My city ar County /'(v+
$ which mquima a permit to convect,alter,Improve.demolish,or repair any structure 1101
prior ke its lssuance,dw requires the applicant for such permit to rile a signed summenl
< that he is Reacted pursuant to the provisions of due Contractor's Ucehhre Law(chapter 9 Sq.Ft.Floor Area Val I �00
(Commcming with Section 7000)of Division 3 of Ne Buslnessand Proresslons Code)m
3 Nu be ,eaempt therefrom and the bub for the alleged exemption.My viol Won of duo IN 'ill
Section 7031.5 by any applim,far a permit mbjecb the applicant M a civil porosity of APN Number
not mom Nan five hundred Callats($300).
❑I,uawmorthepmpmy,amyamploymwithwgumthirmlemmpanudon, 36912018 00
willdohisswork,endmesu mbnotintendedmonemdfmsak(Sa.70M,Busims
and Professions Code:The Contractor's License Lew dm Out apply 0 an owner of Required Inspections
propemy w ho bullds ter improv themon.and who does umh work himsel f ar through his
Own employees,presided that such Impmamcnume naNntsnded craResW futile.If.
however,the building or Improvement Is mid within au year of Completion,the owner.
builder will have the burden of proving that he did oat build or Improve for purpose of
saic)
es owner of the property,am esclusively contracting with Named Conuuen to
comwct the project(Sec.7044,Businees and Professions Code:)The Centncer's U. .
me law dm not apply 0 an owes of property who Whi,or Impmws the con,and.
who contracts for such projects with a contractor lanud smto the Contractors
License Law.
❑tun esempt up 4z B&PC lorthis rquen
owner Dam 7 I
WORKER'S COMPENSATION DECLARATION
I hereby salon under penalty of perjury one or the rolkwing declarations:
❑1 haw and will maintain aCeNftcato of Conserv to self-imus for WorlmesCompen-
ution,u provided far by Secdern 3700 of the labor Cade.far the perfarmma of the
work for which this permit is issued.
t]1 hew and will mainWn Workefs Compensation htseana.a acquired by Section
3700of the labor Code,Bar the performance of the wart for which this permit is heated.
My Workces Compensation Insurance carier and Polity number am:
Carom Policy No.:
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
mebsecdoa recd nurbecmpimcd if the permit Isf rronc hundred dollars(1100)
or loss.)
1 artily that in the performance of the work fo ilei is permit b issued.I shall am
Crept anY'permnin m�manoa��asm budh�6se Irethc W/rkc Camquuetan
LA or Califomla.n.rr�' w 7//�/ !/
Applicant T�-���—
NOTICE TO APPOCANT:11.after math this Orfifleau,of Exemption.you should
became subject to the Workers Compensation provisions of the Iabm Cade,you muse
.J O forthwith comply with such provisions ar this permit shall be deemed moked.
Z CONSTRUCTION LENDING AGENCY
(gin I hemhy affirm that them is<mnbunmr lendin{agenry or the performanaaf
ai
the work fur which this permit Is blued(Sec.3097,Cl,C.)
W Q Under&Name ,
z Leader's Md.
U i certify that 1 haw mad this application and sum this to above information is
W t" caner 1 agree to comply with all city ud County ordineaae and sum law relating M
DU building construction,and hereby authorim mpmmnutiws of this city to enter uponto
W show-mentionetl properly for Inspection purposes
gL (We)agree to save,indemnify and keep homeless the City of Cupertino against
fA liabilitics,)udgmenu,cuss and expenses which coy in any way we=against said City
t.)z In consequence of the granling of this permit.
'••' APPLICANT U T ND WILL PLY ITH ALL N-POI Issued by: Date
SOURCE Ria L
7Z/ 9/O Re-roofs
sig ornppnean o�—
HAZARDOUS MATER Ipa DISCLOSURE Type of Roof
Will the applicant or forum building e.Chapter
or handle Health a material
u de0ned by the Cupertino Municipal Code,Chapter 9.11.and the Health and Safety
Code.Satatz553y(e)7 —�/ All roofs shall be inspected prior to any roofing material being installed.
❑Yea y�•Ivu
Win the applicanuOccupant or fum building upant sae equipment or devise which If a roof is installed without first obtaining an inspection,I agree to remove
halt hevankno eirmommittants as defined by the Bay Area Air Quality Management all new materials foi inspection.
DisuinT
❑Yrs
I have mW the Meadows materiels requirements underClupmr 6.95 of the Cdifor- `�Z
/ y ��
rb Health&Safety Code,Scetm 25505,25533_k.05534.1.&,a"to lime balding / /
dm not turmoil haw e��ccomaa the,It b m onsih'i/to whir the apupant of Ne
mquimm c st�Mm/priori eco Beale orOcc ancy. S• nature of Applicant Ie
Sn(
ow r or omhodT<d sent 7 m All roof coverings to be Class"B"or better