04060020 q , ""VE
a � `CITYOFCUPERTINO " OPERMIT CUI RGfQWN�ieuanwo-iiy)slon I Ir}TIOI, a
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'BUILDING ADDRESS" PERMIT NO. a •'
J HfLEWI,S. GENERAL CONTRACTOR,, 04060020 . ;.
OWNERS .'s'M .. t. y PERMIT L99UB DATE y1 -
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1 Jf Tr1,�Tr v pt t: � SANITARY 0.-4
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ARCHITECT/ENOINg6R .,rL drn i a - BUILDING PERVITINFO f
;S .. (-REDO ELECT iPLUMB .,MECH
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>✓op LICENSEDCONTRACIORS DECLARATION ^- •...' ,f
1 yil hereby affirm thatl mlceucd underpoaaons of Chapter m
r9(eomerwing y Job DeSC17pt10n'
With Section 7")of Diision 3 ortheactions,and Prillaman.,Codesnd my license is i'� j
mfunmretanden t,i:
Lk.N ', FAMILY ROOM ADDITION 491 . SF
py�Z .cense Class -
= c Date Comwcmr %KITCHEN REMODEL
'67f r ';ARCHITECTS DECLARATION I
m 1
U
.4eravirld MY plana shell Ise used u p M c recmda i
y
Licensed Pmfiessmnal' ' ��
i OWNER BUILDER DECLARATION {,r
f (.`f 1 hes.hy tfOrm Net{am exempt from the Contractor's License I:ew'for the - - tt
Ra whichingreunn (Sccdon 70JI30uaiuu and Prof undi Codoepaiany
ay nreaumY - •i 4
M$ which'req Inca a permit to cnnswcf eller.improve,demolish,or repair anYsvunus. - k '" ' { .�0 _ t
prior m 4n ruussce.alaos.qurros the applicant forsuch permit torile a signed statement, t,Uap
p� < that lip I.licensed pt....to the pro'slonsof NC Con,mcter's Lls.ense rise(Cheptes9 :Sq.FL•FIOODArea� is : j...-y ' _ a�Ujari 00,
y $
(eradicating with Section 7000)sf Division 3M1he Bvsincuand Paderai...Cad.)., ` v
Nat he Is exempt dmmfrom and the buffs for.the alleged esempamr.Any violation f
'Scotian 7Bnis by say appucdruoi a pemitsubjecu the appncam m a crvR anauy af. APN Number Occupancy,Typ9
not mos.Nen five handled dollen(5300)." i �,
32645006 . 0.0
Q1,"u ..
ownesof rjie property,army with wages uNe recite eompenu0on . y '
illdo thew'ork:end trawnule is nminhoubd arofrered far,.].(See.7044,Business - Required ons
ired Ins ecti '
and.Procedures Could:The Conuecthi's License Law Coon t apply in an owner of .. - ,q p r '
property who buddsorimprowa themon,and whodoessuch work himselfarthrough his
own empteyoca provided that such improvemenu are not intended in offeredfor We If, t-
hm0everNebuildingBRinprowmenJtaioldwithlnoneyear.ofcamphuds,Neownu
'r, dl have the added of proving that he did not build or borrow for.puryose of
,
o
bmlde
ala)•'"r I�S)t`A5$ 6i'I'1 i vs 5f IK�,h 1 °r° vr''"p !t a[:' v,Iq,e� - .. r .), ..
1.u owner ofdk'pmperty are exclusively Conducting with licensed'contractors to t
[MCI tiro project(Sec 7044 Bureau and Facilitation Code)The Contractor's I.I. -
cense Law does not apply to an owner of progeny who,hulldsor Improves thereon.anti .
,who conaecu uch far sproKeu c
with a ontracler(O the licensed Famous,to Convector's
Lkence Lew,) �I
❑'I am exempt r,Sec. &PCf-9lmsmpsm .,
Ow 'r /.. If ate '
WORKERS COMPENSATION DEC N �
l he aBim unJer penalty of perjury cine of rhe following d Iaretiona:
haws will meinVinaCcniOute of Coaaenuo eels-incus.far,Workci'e Comped- e• ' - - ,
M,o..u providetl.far hy Sitiutid 3700 of the I.ebar Code.Tai the Performance of the j t
'work for which this Noraft is issued.
. t]'I haw and will maintain WmIces Compensauan las,Mance,u required by Section -
37W of Ne Labor Code.rer the performance of the work for which Nis Permit s issued.
My Workces Compensation Insurance e.nicr and Policy number arc: -
Canier
I'� . 'CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE r
"(Thh section ncotl no,IroaomPlekd if Ne pcnnil is fnranc hundred dollars(SIM)'
` oaf ICV.)'
1 cenify,Nm!in.the pcdua tine of the work for which this pcimit it bad ad l shall not
employ any person inany madmrm u m become subject to the WorkersCompensallon -
Laws of California.Date -� -
Applicant
NOTICE TO APPLICANT`Ilf,aflirr drilling this Ceaificam of Exemption:you should` -
t become subject to the Worcces Compcuation pro n o a cattle Lshnr Ctidc you mush -
�Z forthwM camplywW iuch pmvinons nn Nn permitehell be dr<meds.raked „,:, i' .. /" _
1
Q ! ki7NL Y, ENCY§
'yiCONSfRUCTiON LENDING AGENCY '
huahyoffum thmthcre a s'emaidch nl ndmg agency to Nc pgrformmce of
Cdr Ne work fur' hico thio peamti n istwd(Sec ]099 Civ.
{i)
snicest Name '
=Z Lender's Address -
U Q ', I certify.that I have read this application and sato Net Ne thew information is
FCorrect:I agree to comply with all city and county ardiunces and tisk laws telating to s
DYJ building convection:and hereby authorize representatives of this city to enter upon the
shove-mentioned property(or inspection purposes .. ,
(We)agree to taw,indemnify and keep humleu the City of Cupcnino against 7
WL!nCorect,
lities,judgmenu.coca tad expenses which may in any way accrue against saidCity -
C)7ucnce egrimingof this perm:.' - '
CA DERS ANDS AN WILL COMPLY WITH ALL NO Pol Issued by: ,.DaRCE LA C�
` � Re-roofs
S' natur o Appl anvConuactor Date
- HAZARDOUS MATERIALS DISCLOSURE �i Type of Roof
Il the applicant or future building uccupamnom arhandlc a' ous malnrial
ai d f ed by dm Cupertino Municipal Code,Chepkr 9.13,and Ne Hcalth and Safety
Cade.Se don25533(an All roofs shall be inspected prior to any roofing material being installed.
„"Ccs, %No
-Will Ne ippltern or future building occupant use equipment at devices which If a roof is installed without first obtaining an inspection,I agree to remove
ii na'rudou air cmminnu ¢nu u dcOncd by the Bay Area Air Quality Management all new materials for inspection.
Disvlet?
'- - -
QYes .4�yNu '
y� .'.IhaJc real the haisrdn/u`s''memrielsmquis.mcnu uhdcr Chapterfi9SofNa Califon' '- ` -':: .. - '
die HcalN&SafciyCodc.gc[doai 25505.355]3 end753J4.1 undersrana thuif NC Niilding' ;.. _' '� -�' ' - �.
Jae rang hBw:a¢nanV the it limy respo sbility m notily Ne atiu ,of
rayuimmca tp' :Monaco of a Ccldicateof Occupu Signature of Applicant Date
o r oriv<a agem m All roof coverings to be Class"B" or better ��