04050010 JILDING
F CUPERTINO >a q ��'rr' "`gy�, pp ��ryry�� '��yy,��
ING DIVISION - PERMIT <ts.1 'QT,O .�L1i.0i"AT,
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DRESS: JEFF REY MILLER, GENERAL C "`04'050010
841 MC CT.RT.T,AN RD
ME: PERMIT ISSUE DATE
UL & JOANNE KA
SANITARY NO. CONTROL NO.
(408) 866-1345
ARCHITECTIENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
p
Y00F LICENSED CONTRACTOR'S DECLARATION Job Description
M0 S 1 hereby affirm Nat 1 am Indicted under previsions M Chapter 9(commencing
with Section 7")of Division 3 of the Business and Profeasi0m Code,md my license is
'a m in ademn REVISION--CEILING PLANS
Rg License Class Lic:p
qqA Dam Costumier NO NEW PERMIT ISSUED/ORIG. #04020069
ARCHITECTS DECLARATION
I understand my plans shall W used as public incnrds
0.6
C Licensed Professional
OWNER-BUILDER DECLARATION
in
I hereby affirm that I am exempt from the Comracmr's License Law for the \
O D following mason.(Section 703 1.5,Business and Profcasions Code:Any city Or County
dem
x m which requires a Permit to construct,alter,improve, ollah,or repair any structure
www' prior m is issuance,3150 requires the applicant for such Permit to file a signed statement
£F?Q that he is licensed Pursuant to the previsions of Ne Commeter's License Law(Chapter 9 Sq.Ft. Floor Area \ Valuation $0
y $ (commencing with Section 7")of Division 3 of the Business and Prafcssion,Court)or v
y that he Is exempt themfrom and the basis for the alleged exemption.Any violation of
Section 7031.5 by any applicant for a permit subjects the applicant 10 a civil penally of AFN Number Occupancy Type
not mote man Eva hundred dollars(5500). 35714049 . 00
❑I,as owner afore property,or my employees with wages as their sole compensation,
will do the work.and theawetum Is not intended oroRend foliate(Sec.70",Business
and Professions Cada:The Conuacmrs License Law does not apply m an owner of Required Inspections
property whobuildsorimproves therma.andwho do Bauch workhimself orthrough his
own employees,provided mat such improvements are not intended militated forelle.If,
however,Ne building or improvement is sold within one year of completion,the owner,
builder will haw the burden of paving mat he did not Wild or improve for purpose of
' sale.
1, x no,of the Property,am exclusively conducting with licensed contractors to
construct the project(Sec.7804,Business and Professions Cade:)The Conaractor's Lt.
edged Law does not apply to an owner of property who Wilds or improves thenon.ad.
who contracts for such projects with a communalist licensed pursuant o me Contncmr's
License law,
❑lam ex On eQ' ,B&P C for this reason
D
)PREER'S COMPENSATION DECLA IZIO
I hereby arms multiformity of perjury oneof0d followin dedansom:
I lum and will mainWn a Cenifmam afConwnt W MY-intra for Worker's Corepen.
said.,as provided fm by Section 37W of me labor Cade,for the performance of the
work for which this permit is issued.
01have and will maintain Worker's Compensation Insurance,as required by Section
0of the Labor Code,for dm performance of the work for which this permit is issued.
My Worker's Compensation Insurance artier and Policy number am:
Cartier. Policy No.: _
CERTIFICATE OF EXEMPTION FROM WORKERS' r
COMPENSATION INSURANCE -
(Thu section need not be completed ifthe permit is for one hundred dollars($10))
or itis)
1 certify Nat in the performance of the work for which this Permit is issued,I shall not
employ any person in any mannersn as to become subject to the Workers'Compcnstrion
Law,of California.Data
Applicant
NOTICE TO APPLICANT:If.after making this Contrition of Exemption,you should
become subjat in the Worker's Compensation provisions of the Labor Code,you most
Q Z forthwith comply with such provisions or this Permit shall be deemed invoked.
„zi O CONSTRUCTION LENDING AGENCY
[—r I herchy Nmm mat dem is a construction lending agency ler me rerformmce of
lYi> the work for which this permit is issued(Sec.3(197,Civ,C.)
QLender's Name
]z Lenders Address
O Q 1 certify that 1 have rad this application and sate that the above information is
IL correct.l agree to comply with all city and county ordinances and auto laws brisling to
0 building conswction,and hereby authodm mpresenutives of this city in enter upon me
4 above-mcmti0md properly for impaction purposes.
(We)eSom to save,indecently tad keep harmless the City of Cupertino against
rFw to liabilities,judgments,casts and expenses which may in any way accrue against said City
U Z in consequence of the graining of this Permit. t
s4o�
rS.W.n
ANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT Issued by; Date
"
124 $-O Re-roofs
.toman ontruto D re
HAZARDOUS MATERIALS DISCLOSURE '1� Type of Roof
Will Me applicant tarfumre building Occupant store or handlehvu mriai
the Cupertino Municipal Cade,Chapter 9.12,and me Health and Safety
n zss3z(a>? All roofs shall be inspected prior to any roofing material being installed.
s J7S-Nume applicant or(m rc baRaimg ocanpantaw egmpmat or devises wniahIf a roof is installed without first obtaining an inspection,I agree to remove
us air comodem.in g defined by the Bay Area Air Qality Management all new materials for inspection.
(,��(�,(/�s
Ihave mad the de.Saceuna 25505,2553als and ntsZ53 under Chapter G95 ofthe Glding
nial Iciuth&SofctyCoM.Sccall, at 15.mymsnd75bility34.I understand that Wilding
dors t curtcmly nano Net It a my brspomihility m notily We ucupent of the
tell ,en w in ,. to aofscerdfiateam
of cy. Signature of Applicant Date
r0n;. agent
d All roof coverings to be Class 'B" or better