04050103 CITY OF CUPERTINO —
P�RMITBUILDING DIVISION � �OkbrF46'C♦1' °"''f� '
1� 1
BUILDING ADDRESS: 1E1MITNO04050103
OWNER'S NAME: - PERMIT ISSUE DATE
CHRISTINE SHE
E: SANITARY NO. CONTROL NO.
ARCHITECffENGINEER; BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
z LICENSED CONTRACTOR'S DECLARATION Job Description
I hereby affirm that 1 am licensed under provisions of Chapter 9(commencing
with Section 7")nfDivision 3 of the Business and Professions Code,and my license is
�m mfull home and affect,
ADD 913 SQr FT. GARAGE 417 SQ. FT. REMODEL
License Class Lie.N
Date Contractor
ARCHITECTS DECLARATION
�v 1 understand my plans shall W used as public momma
it76
G Licensed Professional
OWNER-BUILDER DECLARATION
<� I masa affirm on I am exempt from she fessins Co License Law for she
p�o� followhich ire massa Permit
7f131.5, amr.a and improve
demolish.
Cade:Any city or county
which its Wo a permit men,also re construct,th alter,ice for such
demolish,nr repair any structure
H priori incensed pimimintto the theapplicantfor Cmnrormitmfiele s Law statement
xix=< shelhcencinwit Pursuant to the of Division
of thecRusinssm License Law(Chapur9 Sq.Ft.Floor Area 2 Valuation
y F$ Z,he I.
exam with Section 7(qd th Division 3 of the aged errand Proon.Any
Cook)la"n of 1'
�.. Net he u exempt Umrcfrmm and dte breis for the alleged exemption.Any violation of U_
Section 7031.5 by any applicant for a permit subjects the applicant to a civil Penalty of 3 A3`NH G&'ber0 0CCU araC
nm mom than five hundmd dollen($500). P Y Type
❑
will do
owners,she pmpeny,ter is intended
cared for (Sec.
mmpenmtlon,
will dothisund Cdic no wmisnoll Livens Law
front (S.c.he a.Business Required Inspections
and arty who
Cada:The ves domear'a License law does not apply lf an owner of q p
property who builds oded ditvemch fire,and who meuudt work himmlforthrough his _
own e however,
the building
provehimprovementsarenalintendedmoQeted forthe owner,however,Nebuilding hor aimprovementis sold within one year of completion,the purpose
of
builder will love Um Wmen of proving Net he did not Wild or improve(m puryam of
m J.
.or of the property,am exclusively mumsting with licvued.mntmcurs to
eons.at she project(Sec.7044,Business and Professions CudeO The Connector'.Li.
came Law does not apply to an owner of property who Wilds or improves thetean,and
who contracts for such projects with acontnetor(s)licensed pursuant to its Contractors
License law.
❑l and exempt under Sec. ,B A,PC for this mann
Owner
WORKES S COMPENSA ONII` n I AlOsTION
1 herby eRrmunder penally of perjury one of Ute following decimations:
1 have and will maintain a CeABcate of Consent to self-insure for Worker's Compen.
cation,as provided for by Section 37W of the labor Code,for the Performance of the
work for which this permit is issued.
❑I have and will maintain Worker's Compensation Insurance,as required by Section
3700 of the Labor Cad..for the p.rformanca of the work for which this permit is issued.
My Workers Compensation Insurance carrier and Policy number am:
Cartier. Policy No.:
CERTIFICATE OF EKEMMON FROM WORKERS'
COMPENSATION INSURANCE
(Thlssection need not Winandided If she permit Is formas hundred dollar,(SIM)
or loss.)
1 unify that In the performance of the work for which this permit is issued.l shall not
employ any person in any mann.,.as to become subject to the Warkcrs'Compeemiu n
Laws of California.Data
Applicant
NOTICE TO APPLICANT:IL after making this Certificate of Exemption,you should
become subject he the Worker's Compensation provisions of the Lahr Coda,you must
.J O forthwith comply with such provisions or this Permit shall W accrued tevnk.d.
'y CONSTRUCTION LENDING AGENCY
I-i 1Wrahy alarm that there is a construction lending agency for The performance of
a the work far which this Permit is issued(Sec.3097,Civ,C.)
W�A Lender's Name
z Lender's Address
[J Q I certify that 1 have read this application and mute that the above information is
IL H correct.I agtee to comply with all city and county ordinances and site laws relating to
DU building construction,and hemby authorise rapresenutivca of this city in enter upon the
W shove-mentioned property for inspection PUTOWL
y (We)agree to save,indemnify and keep harmless the City of Cupertino against
t,y fA liabilities,judgments,costs and expenses which may in any way acme against mid City /
(„),'L in consequence of die granting of this Permit.
a" APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT Issued by: Date
50 REG 'MONS.
v /lUq' Re-roofs
ign ure afApplic HAZARDOUS ATERIALS DISCLOSURE Date Type of Roof
Will the applicant or future building occupant store orhandle havardous material
as defined by the Cupertino Municipal Cade.Chapter 9.12,and the Health and Safety
Code srceon 25532(1)7
❑Yes )(NoAll roofs shall be inspected prior to any roofing material being installed.
l Will the applicant or fulum Wilding occupant use equipmentor devices which If a roof is installed without first obtaining an inspection,I agree to remove
It hezamous air contaminants ss colund by the Bay Arca Air Quality Management all new materials for inspection.
inrict?
❑Yes No
1 have mad the hasamous mannialm mquirma nu under Chapter 6.95 of the Califor-
riaHeal"SainyCosis.Seetiens 25505,75533 and 25534.1 undersund that if the Wilding
dors not currently hove a miens,that it u my rcspamiWity at notify the recupmt of one
rcyuimmcnuwhichmmiWmet pdormissuanccofaCc 'ficau mf OccuPmcy. /
7 / U
Signature of Applicant Date v
wear or aushorimd agent Dale All roof coverings to be Class "Bi'or better