08060112 CITY OF CUPERTINO 'e- wa..��#..
BUILDING DIVISION PERMITC�NTRAG:TQR INk'U�R r1TION,
BUI 1' KESS: PERMrr NO.
MADERA DR TBD TO BE DETERMINED 08060112
,.R'S NAME: - PERMIT ISSUE DATE
SI.MONE & DROR HAROUSH 06/25/2008
PHONE: SANITARY NO. CONTROL NO.
ARCHITECTIENGINEER: BUILDING PERMIT INFO
-BLDG ELECT PLUMB MECH
0 0 0 0
tion LICENSED CONTRACTOR'S DECLARATION
m❑ 1 hereby affirm Nat I am licensed under p o nsioes of Chapter 9(...in, Job Description
ZW with sectionT0OU)ofDiOnion3ofdhe Business and ProksskmCade,and mylicense is RMDL 1ST FLOOR & BTHRM INTO UTLTY
i'qi �nicfull tlfo� and ercnce ueg ROOM(162 . 5SQ&216SQ) 2ND FLOOR BATH & REPLACE
al Dau ARCHITECTS DECLARATION WNDWS
D6g7W I understand my plans shall be used u public records
u CHGD IN SAME FRMS, REPLC VINYL W/STUCCO
In Licensed Professional
5 OWNER-BUILDER DECLARATION
v�
1 MRm that the f thereby at I am exempt room Cmaanora License Law for the
C
0 o following reason.(Section 7M LS.Business and hafauom Code:Any city or aunty
S$ which me,fires a permit to construct alter,hnpreve.demolish,or mpur any structure
_Ze prmrwitsissuance,awrequimslMappliea 1 forsuchpermittafil,.signedauucum
ssIlutheulicenudpursuanttotheprovisioonoftheConuactmbLicenseLaw(chapter9 Sq.Ft. Floor Area Valuation
irk•$ (commencing with Snction7")of Division 3.1the Beat.and RafessiOruonce)M $65000
thst he Is exempt Nraefrnm and the basis for the Wl.gcd exemption Any vtoladun of
Section 1031.5 by a"applicant for a Permit ub*ts the applicant 10 a civil Penalty OfNumber Occupancy
T e
set more than finhandmdmnars(SSEQ 32635028 .E P Y YP
I,u ownv of the pmpertJ'.ser mY emplgma with wages a their sok cvmpenssdon,
willdothework,and Neswctumurwtimmndcd.,offeredferule(Sec.'f014.Bu eras
and Professona Code The Conmcwrs License law Coma mf apply w an owner of Required Inspections
Property who builds or impmw daemon,and who does such work himself or through his
owocmployea,provided that such improvements=not intended oroRerad for sale R. _
however.the building.,improvement is told within one year.(Completion.the owner-
, builder will haw the burden of proving Nat he did net build or improve for purpose of `
sale.),
-1.`"owner of the Property,am exclusively contracting with licensed contractors he
.omwct Ne project(Sec.1044.Business and Professions Cad.:)The Conummes V. .
cense Law does not apply to an owner of property who builds or improwa Neman.and.
who contracts for such pmjc=wit a conuxwr(s)licensed Wrauant to lite Contractors
Lkenae Law.
•sun uco;ptunde See - -- ,BAPCf.r Nismatm .
Daum Q
_WORKERS COMPENSATION DECLARATION f "
I hereby affirm under penalty of perjury one of the following declanu.os:
1 hsw sum wVl maintain a Cenifiate ofCortsent w self-insert fa Workers C.mpem
salon,as provided for by$cedars 3100 of the Labor Code.for the perfomtmee of the
work for wlJeh Nis permit is issued.
0 1 have and will muntsk Workers Compensation Insurance,as mquimd by Section
3100of the labor Code,fm the performance ofthe work for which this permit is issued. '
My Workers Compeuation Wuran a artier and Polity number am:
Cartier. Policy No.: _
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(Thh xetim head not be completed if the permit is form.hunched d.11.($IOq
or leu)
1«wfy Not in the performance of the work for which this Permit is issued,1 shall not
employ any person Mary moar to ss w bemmc subjaf w theWahCri C0,9pensadm
Laws of California.Da
A
Nppliam If.after making this Ccniilate of Fico tion,you should
become subject to the Workers CoroWnaadm provisions of the Labor Code you maw
.J O rouOwith comply with men provision m this permit shall he deemed mvnkcd.
z� CON=ucrION LENDING AGENCY
(-n Ibumby affirm that Nem is a construction lending agency for the Performance of
O'. the work fur which this,pcmit is bouW(Sm.5l9T,Civ.C.)
LsaW sNana
Z z Lenders Address
UO 1 certify but 1 have mad bus application and tau dor do above infoonadun u
D.E correcL 1 agree w comply with N city and comfy on inmces and suss laws mlading to
.O building mnstrucsion,and hcmbymdorim mproenatives of Nis city to enter upon the
oned
aabw-monudgm ntapeny fors apcn cal goopmwhich a
F 0. (We)agree to save,indemnify and keep harmless the City of Cupertino against
h in
quence f On,foto and of,financing this
may in any way scene quarto said City
U Z A(��P�PP�L consequence
UNDERSTANDS ANDWILLWILL COMPLY WITH ALL NON-POINT Issued by: Dale �y r L
.SDURCE EG3
J Re-roofs
ApplicanuComn OU Dau
HAZARDOUS MATERIALS DISCLOSURE Type of Roof
Will the applicant or future building mcupantaom rehandle hazardous material
Med by dm Cupenin.Municipal Code.Chapter 9.12,and the Hcuth and Safety
c,Led.n 253J2(a)1^
❑Yon �N. All roofs shall be inspected prior to any roofing material being installed.
Will N.applicant or future Wilding occupant sex equipment m dev our which If a roof is installed without first obtaining an inspection,I agree to remove
Dand isuktl�nm air cona!mzl yl u dented by the Bay Area Air Quality Management all new materials for inspection.
❑Yes QNu
I have mad due h ardwu maurialsrequimmcw under Chmur6.95ofNe Califon
aux Hal&SA ty Codc,Sectiats 25515,25533 and 25534.1 understood thatif thc building
dons out currently have•means Nat it u my responsibility to amity the occupant of One
mqulrcmcntsw hmuubemetpri.rmiuunuxar.Cwficau of p3p�
(U pts]' Signature of Applicant Date
owne,msuthmized agent Date All roof coverings to be Class'%¢"or better
9+