05030148 CITY OF CUPERTINO
BUILDING DIVISION PERMIT CONTRACTORINk'ORMATION:
BUILDINGADDRESS: n DADE BEHRING PERMrr"05030148
OWNER'S NAME: PERM)T ISSUE DATE
E: SANITARY 0. H60ROL NO,
ARCHITECT/ENGINEM: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
nor, 0
u w FOC 1 herby at 01LICENSED n OaN�under CTOR'PDECLARATION
ofChapter 9(commencing Job Description
-iW with$.,..TIX10)af Division Sof he Business and Profession Code.and my It..is
's u, in full forte and effect
License eCwLie.• REVISION--IN HOUSE USE ONLY
ii- Dam CmUactar NO NEW PERMIT ISSUED/ORIG. #04080144
44'Js ARCHr1EC'S DECLARATION
?W U i undqp y plaeyshall MCd u public records
3n d 1
. n
Licensed ProfessionalC
n 3 OWNER-BUILDER DECLARATION
3 0 C I hereby affirm that 11. exempt from dm essio no(s License LAW for the
p o fallowing reason. etch t Stn LA Business and sae,de el Cade:Any city or county
$w which requires•permit re ennswe, alma improve,demolish,Fie pair any structure
FZY poor at he I,2lesedpe.also uantto T316mvismieator.f forthe C.O urcmlil bicense aw(Cned dlemenl
€ otcommencingwJpurstiol7the")ofDivionafNeConuxmr'snicenselsonCode)or Sq. Ft. Floor Area Valuation
$35
e F`$ that he racing with Section7")and the
Division 3 of uses Business and Professon.My vi Code)of
_
that he u eumpt therefrom and the baso for the alleged exemption.My violation of
Section 7031.5 by any applicant for a permit subjects the applicant to a civil penally of Aane PN Number Occupancy Type
.at mom then five handled d.11.($=. P Y YP
1.in owner of the pmpwY or my employees with wages as their We compensation, 31622018 . 00
will do the work,and the swctum isnot intended or offered tamale(Sec.70,14.Badness
and Profession Code:The Contractor's License Law does let apply to an owner of Required Inspections
Own
property who
yees.ro ided that such impr and who doessuan,nmch work himulfad for ughWe his -
awn employcWiprovided that such impmvemmu an,net ear of completion.
aro@red for sale.r.
Milder .Nebuildingorimprovementissold withinone year of mprove fn,theowner-
builder will hove the Mrdcn of pressing that he did not build or improve for purpose of
W.J. l'
1,as owner of the pmpeny,am exclusively contracting with licensed eonvacmra to V
contract the pmjen(Sec.7W.Business and Profession Code:)The Commatoh Li.
come Law docs not apply to an owner of property who builds or improves themon,and.
who contracts for such pmjecu with a conuactons)licensed pursuant to the Cuntraetoes V
License law.
O lam eumrr�pttrotor See T,B It P C for this on
Owner V14 DE' e-E// INom-' Dau —6 d�
WORKER'S COMPENSATION DECLARATION
730111 hereby aRum under pwalty of perjury ane of the,following declarations:
ve and will maintain a Cenificam of Consent to selfAusure for WarketsCompen-
,
f.provided for by Section 37M of the labor Code.for the performance of the
for which this permit is issued.
ave and will maintain Worker's Compensation Insurance,as requimd by Section
ofthe LaborCode,for the performance of the wok for which this permit is issued.
orkees Compensation Insurance carrier and Policy number am:r. Policy No.: _
CERTIFICATE OF MEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(Thu auction recd not Meomplemd if the permit Is intone hundred dollars($100)
or mss.)
I cenify that in the performance of the work for which this permit is issued,l shall our
employ any person in any manner an as to become subject to tim Workers Compensation
Laws of California.Date
Applicant
NOTICE TO APPLICANT:IL after making this Certificate of Exemption.you should
become subject in the Worker's Compensation praAsion of the labor Code,you most
Q Z forthwith comply with such provision or this permit shall m deemed revoked.
Z O CONSTRUCTION LENDING AGENCY
ti
De hereby which
affirm Net there isaeonwcti0lending agency for dm perfmmena of
fY> the work for whim this permit u issues(sec.309'!.Civ.C.)
MW A Iandcls Name
� z Lender's Addle..
U C) 1 ardfy that 1 have read this application and sum Nal Ne above information is
f" correct.l agree to comply with all city and county ordinarmes and sum laws relating to
O[) building cnnsuucoon,and hereby suthodn reprcaunutives of this City to enter upon the
nd
purpo
�c) aMilid"Juogmems.Costs
for desti tion which a
(~y
(Wo)agree m ave,indemnify and keep harmless the City of Cupertino against
C.)Z in colitistuari me n0.cosuandofpe.ermit. may in anyway accrue against said City
APPLLIICANT of DEP NDSthis AND WILL COMPLY WITH ALL NON-POINT Issued by: Date
SOU6rGULATIONS C
/l
Stgnmrt ol'App licard' Date
Re-roofs
HAZARDOUS
MATERIALS DISCLOSURE Type of Roof
Will the applicant or forum building c.Chaptamm oranddo n eallous material
u defined by tlx:Cupertino Municipal Cade.Chapter 9.12.and the Health and Safety
Calc,section 25532(ap
❑Yea ON. All roofs shall be inspected prior to any roofing material being installed.
Wilt the applicant or future building arupant use equipment or devices which If a roof is installed without first obtaining an inspection,I agree to remove
havardnm air communities as dcfad by the Bay Arra Air Quality Management all new materials for inspection.
den P
❑Yes ONO
I have mad the haardrws mamnal,mricilemenu under Chmmr6.95 of the Califon
ria Halm A,saIclYCadc.Scene.Z5%5.25533 vd255M.I understand thm if the building
does let c w as[• that it u my resmratibilily b testi ry do,occupant of the
myu' nichmast`=ct �Ssnanccrracemreamarampaney. Signature of Applicant Date
Owner or aamorized agent \) Dam All roof coverings to be Class "B"or better