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03090096 CITY OF CUPERTINO ` " •' BUILDING DIVISION PERMIT CON RACTORANT+U�MATIUN: BUILDING ADDRESS: TIMBERLINE BUILDERS INC PERMIT No.03090096 477 T.TNTT)V TIT ER'$NAME: PERMIT ISSUE DATE 4 NE: SANITARY NO. CONTROL NO. ARCHITEC(ENGINEER: BUILDING PERMIT INFO BLDG ELECT PLUMB MECH a�Op LICENSED CONTRACTOR'S DECLARATION O O O O 1 hereby affirm Nat I am licensed under provisions of Chapter 9(ammenciq Job Description wide Section 7011)of Division Sof be Business and P Ionscmicandraylicen is -- ^ � inm0fblaasraettee 6 2�j x �REVISI_ON- IN HOUSE USE ONLY q z LlcenmCkss L e.pE,y,I A—'c Dow Contractor N RMIT ISSUED, ORIG. 402080091/ �e ARCHITECCSD$CLABATION y tune and m plans!all W uscQ,C WM(c maxed, Licensed Pm cssiomi 3 OWNER-BUILDER DECLARATION 1 ha."affirm that 1 am exempt from the Co moor's License law for the a O following mason.(Seedun 7031.5,Business and Professions Code:Any city or county $ which requires a permit bs construct,a@e improve,dcmoluh,or repair any structure y prior to its issuance.also requires the applicant(orsuch permit to file a signed statement that he is licensed pursuanuo the prvisiomnf the Cmarectur.License Law(Chapter 9 Sq.Ft. Floor Area Valuation $o m $ (commencing with Section 7000)of Division 3 ofthe Business and Professions G^tlC)Ur V .. that he is exempt therefrom and be buffs for the alleged exemption.Any=of Section 7031.5 by any applicant for a permit subjeces the applicant to a civil penalty of APN Number - Occupancy Type not mole then five hundred doll..(5500). 01.ss owner of the property,or my employees with mitoses bebaole compensation, 35624004 . 00 will do be wads.and Ne strudum isnotintestded oroffemd foram(Sec,IDN,Business and Prefessiam Code:The Communes License Law docs Out apply to an owner of Required Inspections p ropeny who builds or i mpmves beceon.and wha sires such work himself or through his awn employees.provided thatsuch improvements are not intended mattered for sale.If, however.the building or improvement is sold within one year o(compledon,the owner- builder will have the burden of pmving Net he did not build or improve for puryose of .Is I. `© ❑I,as owner of the progeny am exclusively contracting with licenced convectors w C-> construct be project(Sec.7044,Business and Professions Code:)The Commumar'a U. V cane raw docs not apply w an owner of progeny who sed p or improves Comeac and \ who conmcu for such projeeu with a convactor(q licensed pursuant to the Conmetor's rase law. exempt under Sec. .E&P C for this moon . or Date WORKER'S COMPENSATION DECLARATION 1 hereby affect under penalty of perjury mm of be following declarations: have and will maintain a Certificate ofCamenuo sof-insure for WurketaCompen- .m provided far by Section 3700 of the Labor Code,for be performance of be for which this permit Is issued. have and will maintain Workers Compensation Insurance,ss required by Section of be labor Code,far be performance of be work for which this permit is issued. orker's Compensation Insurance carrier and Policy number are: Ca oImy Na.: CERTIFICATEOFE7 ON FROM WORKERS' COMPENS4 ONINSURANCE (Thissection need notbe completed if due Permit is for am hundred dollars(SIM) or Mss) I comfy that in dee performance of be work for which this permit is issued,I shall not employ any person in any mm�x t ¢coo bjerkers'Campensatlon Laws of Califomia.Date to be Applicant NOTICE TO APPLICANT:If,after making this Cenifscaw of Exemption,you should become subject w the Worker's Compensation provisions of be labor Code,you must Q Z forthwith comply with such provisiom or this permit shall be deemed revoked. ZO CONSTRUCTION LENDING AGENCY [-i I hereby arcem dual Nese is a conswctinn lending agency for the perfurmancc of rl 7 the work for which this permit is issued(Sec.3097,Civ.C.) Owi Q Lender's Name = z Leaders Add. U Q 1 canify that 1 have mad this application and stow that be above information is D. f~ coned.l agree to comply with all city and county oNinances and stain laws relating to Q V building constmcdon,and hereby authons mPmsentatives of this city to cuter upon the (ZI abow-mendoned property for impaction purposes. 0. (We)agree to lave,indemnify and keep harmless dee City of Cupertino egeinn w+h Ilabilides,judgmcnu.coata and expenses which may in anyway same aga tuswdCity APPLICANT UNDERSTANDS AND WILL CO PLY WITH ALL NON-POINT V'Z in consequence of the granting of this permit. Issued by: Date �fl CE REG 10 ate^ 2 h 6y Re-roofs Signatme of ApplicanVConrnctor Dale HAZARDOUS MATERIALS DISCLOSURE Type of Roof Will be applicant or(marc building occupantstoro or handle harmonious material fined by the Cupertino Municipal Code.Chapter 9.12,and the Healb and Safety c,Secdon 25532(¢)? All roofs shall be inspected prior to any roofing material being installed. ❑Yes XNo Will the applicant or future building occupant esu equipment or devices which If a roof is installed without first obtaining an inspection,I agree to remove it hmardaus air contaminants as defined by the Bay Area Air Quality Management all new materials for inspection. District? ❑Yes KN. I have maJ the hmemousmaterials requiwmensunder Chapter6.95 of the Califon nialicalde&SafetyCode,Section 25505.25533 and 25534.1 understand batif the building dowas not currently haw a tonen4 that it is to responihility notify the occupant of be myairc�niaq ichm .=poor wisccrdfi�at,nG(�cu an� Signature of Applicant Date Owner or or authorized agent ✓ �w All roof coverings to be Class "B" or better