04120024 ECITY OF CUPERTWO "'�
BUILDING DIVISION PERMIT ,CONTRACTQR�INFORMATION
BUILDING ADDRESS: EARTHQUAKE READINESS PERMIT NO 04120024
E02
'01E'
ER'S NAME: PERMIT ISSUE DATE
RONY GREENBERGSTANFORD
ShUARY N0. CONTROL NO.
650) 324-3322
ARCHI'fECT/ENGINEER: BUILDING PERMMNFO
BLDGELECT PLUMB MECH
0 l� 0 0
an,O'z LICENSED CONrRACIDR'S DECLARATION Job DESCTI
1 Morin affirm Nn I em liecnsed undo m of Chapter 9(commencing - Description
.flub with 1of Division3ofdm Butt Prof oro Codc.and myliccnscu ,J ,
as,Berzec u; Sd �a VOLUNTARY SEISMIC UPGRADE
X—p Dam Contractor
�e^�t'� ARCH CrSD
y d< 1 un fid yns us(d u pub-To records
0k
30'~^ Lac armmor
fual
S OWNER-BUILDER DECLARATION
<f I hereby affirm that 1 am exempt form the Crmraetors License Law for the
i poo following mason.(Section 71131.5,Busincramd Rofessiom Code:Any city or county
m which¢quires a Permit to m,naorn.him,.improve,comolLsh,Or repair any atrucm,e
Fly priorm its ismance.alw requiresthcapplicam forsuch mm,iuo file a signedstalament
< Nat he is licensed pursuant to the provisions ofmcContractor's License Law(Cltapmr9 Sq.Ft. Floor Area . Valuation '
¢1-$ (commencing with Section 7000)of Division Sof the Business arta Pmfeuinm Code)or
that he is exempt mmefrrm and the hums for the alleged exemption.Any violation of
Section 7031.5 by any applicant for•permit subjects the applicant m a civil penalty of NNut r ,1erO O Occupancy Type
no,mom man me hundred dollars($500). P Y .
0 1,an Owner of dre property,or my employees with wages u their sole compensation,
will co the work,and destructor,unot ismMcd or ofrepol fm axle(me.7014.Businexs
and Professirm Code:The Contractors License Law docs not apply m an owner of Required Inspections ... - .
property who Wildsor improves demon,and whadassuch wmkhimsel(orduoughhis
Own employ=.provided that such imprmemcnts sm not intended Oro@red forsale If. L!/ \.%•' ^�
however.me Wilding of improvement is sold within one yeti otcompledoo,the Owner-
Wilder will now the Writes of proving mat M did not build or improve for purpose of ,r
sale.). /.`y/ 11
0 1,as owner of the property,am exclusively contracting with licensed contractors an R
comtruct the pmlca(See.704x,Business and Professions Code:)The Contractors Li.
came Law docs not apply to an Owner of property who Wdds or impmvu income.and �� / �i f/(' ,� ���"✓
who contracts for such pmiam wit a conuactools)licensed pursmnt m the Contractors
Llccme UW. p`. I' •r
O l am exempt under See. ,B&P C for this won
woer Dam
WORKER'S COMPENSATION DECLARATION
I hereby affirm under penalty of perjury one of dm following decimations:
I haw and will maintain aCertiOcateof Couentm solf-imure for Worker's Condon.
section,u provided for by Section 3700 of me Labor Code,for me performance of the
work for which this permit is issued.
0 1 bate will maintain Workers Compensation Insurance,u required by Stenion
3700 Of me bar Cock,for me performanec.f me work r which oris permit is issued.
My Wer s tion Imurarme canis and Policy n
Cam d C'O Polity No.: Qa
CERTIPICATEOFEK PrIONFRO S'
COMPENSATION INSU NCE
(Thu It.need no,W completed if the permit Is i.e.hundred collars(5IM)
Or less.)
I certify that in me performance of IW work for which this Permit is issued,1 shall not
employ any person in any mmnerw as In b cmc subject m the Workers'Compensation
Laws of California.Date
Applicant
NOTICE TO APPLICANT:If,after making this CcdiEcare of Exemption.you should
become subject m me Works',Cion,rwuon provisions of,ho LOW,Code,you mesa
.JO forthwith comply with such provision or mu Permit shall be cocmed mated.
z CONSTRUCTION LENDING AGENCY
F 4 1 hereby an.that mere is a cmuwctinn lending agency for dm performance of
C the work for which this permit is issued(Sec.3097,Civ.CJ
aA Undoes Name
oz Underi Address
U Q 1 certify that 1 have recd this application and duos mat the aWe l sus misting u
0 U corms I agree m comply wire all city and county mads or and stain laws relating m
U .1socangcationom an and hembymumorimlaprosenta,irrs of this City menter upon me
[Ll shove-(W tionW in eny for i armify n Purposes /�JY
r)Z
(We)agree he cave,indemnify and keep harmless me City of Cupcnino agmina, f
y liabilities,judgments.eosu and expenses which may in any way accrue a&im,yard City
I — '��4
Uz inconmqueneeofthe ting Of uPe WILL
^ APPll,,11CARE UNDE TANDS D WILL COMPLY WITH L DN-PDINT Issued by: Date
SOURCbREGULATI 5.
3 �I Re-roofs /
—177 Of Applican p olctor ♦ -Dela
HAZARDOUS MATERIALS DISCLOSU Type of Roof
Will lheappliem,or future building nccupanu,ore mharidI has Ous malarial
as dc0ncd by me Cupertino Municipal Coda.Chapter 9.13,and the Healm sod Safmy
"MoLteak.Sec ye,zss3z(,/7 I All roofs shall be inspected prior to any roofing material being installed.
�Vp �Nr
W,II the applicant or future Wilding Occupant use equipment or devices which If a roof is installed without first obtaining an inspection,I agree to remove
emit hamrdous air contaminants u dcrincd by the Bay Arca Air Quality Managcmcnc all new materials for Inspection.
District, a,
❑Yes fa Nu
I have mad the hanrdmss materials mquimmen a under Chapter 6.95 of the Cables,
nice Health&SafnyCodc,Secdom 8505.35533 and 8534.I mWcrsurd We ifthc Wilding
dam,ort cuscmly ave a lanana th t i,u my mspowhiI m na,ify-10e up ,of dte
m iremmru whiff mesa be me missulncc ofa Cc '(cam of Oce ry.
a 3 G Signature UfApplicant Date
COwncroraUth...dagcnt „e All roof coverings to be Class "B"or better