05070198 CITY OF CUPERTINO `� u.,
BUILDING DIVISIONPERMIT i o'RT" CTl1RT1�lC C 'I2iVIAT1f71�
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ADDRESS: PERMITNO.05070198
475 MTT,T,ARn In
OWNER'S NAME: PERMIT ISSUE DATE
} RONALD & MARY SCHROTENBOER
Eu SANITARY NO. CONTROL NO,
ARCH=IENGTKEER: BLDG BUILDING PERMIT INFO
' EIPC7 PLUMB MECH
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loo LICENSED CONTRACTORS DECLARATION - Yob Description
b 1 hereby affirm Nn 1 am mmued under provisions;of Chapter 9(mmmendng
with Section 7=)orDivW..7 of me Rumness and Profalskns Cade,red my license is
I FINALE®
+� I.fall faaewaefrom. ADDITION 36 ' DINING. RM
2 LlcmmClass Lk.Y
?g' Dam Contractor SOME ELECTRICAL
7 ails"I N use DECLARATION
1 understand my plans shail m used as public records
f Licensed Professional JUN 941 2005
SO OWNER-BUILDER DECLARATION
r
S 1 ream alarm
that 1 1. ususin from the Cssions c :An c law co Ire
lip
o (allowing mown.permit
t ]117 Lm,Bussu. and ax.de all Cade:And city or county
$ which r its Wo a permit m emmrur.aloe.hnpmse,de Permit
t Co mpur ed m a nom
zi
prim miu iensedprsare to acatthe theapplicanto fu Coir Pcrmitwicensflic e awtChamcm
<
that hee licensedpursuantolheptoviiamofthe mBuacwr'ankcnselswt,Codecr9 Sq.Ft. Floor Area
H s thLOWILM
an a is exempt
pt tkmfmm and
the
Division sfat stun Buttress pt Professions Cade)of
then m V exempt therefrom and de bub fa the alleged exempdaa.Any violation of
Section 7071.5 by any applicant far a Permit wbjeeu the 4PPLi-1 M a Civil Family Of APN Number Occupancy Type
til mom data five hundred dollars(ss0o1.
❑1,u owner cribs property,or my employes with wages u their wkcompenvtion,
Mlldsthework.md Nnmmmu ismti=ndtd CoaQeredforsak(Sec.ttld•1.BLW" Required Inspections
and Professional Cade:71e Carbonate,License Law doer ort apply N an owner of q p
property who builds a im pwsu desmn,mid who does such work himself a through his
awn employees,pmvided then such improwmenu art ort intended Continued fa Wa.R,
however,Ne building no improvement Is Bald whom one year at complodm.me owner.
builds NB ham doe home of pro firg met be did ma build or improve fa purpose of
sak.),
P1,u.of me property.aro excuaively mnuutin'with Bcmue l comuactom w
conswm the project(See.7044,Business and Prafesma ,Cade:)The Cormsemes Li•
ceve Law does not apply an an owner or property-who Wilds or improwa aemmn.Md.
who ennuams for weed projecu what a c ommma(s)Ikansed pursuant in Ne Conto mates
License Law.
❑Ismer plunder Se Avy�f' .B k�P�C fa this 7mawv
131YOO
u f.JCTl3�Dau(/ f��
RI R5 COMPENSATION DECLARATION
I mmby under penalty of perjtry am of ran following demerwanr.
haw and will nue"W"a Cenifiamaf Cavum m self-morm forWorkersConpen-
n,u provides(a by Sutton 3]00 a!ore labCo Code,for the performance of Ne
fa which Nis permit is issoed
have Md will maintain Workers Compensation Imuran¢,u required by Section
M ate labor Code.for ate performance of the work for which then permit u wood.
Warknrs Compensation Insurance carrier and Policy number am:
Carrier. Policy No.:
CERTIFICATE OF EXEMPTION FROM WORKERS
COMPENSATION INSURANCE
(This wmim need not W completed Rede permit D fa one hundred mHare($I00)
m lux)
1 ccmfy Net in the perfmmaoea of the work for which this Permit u imam.I Nail not
employ any person In MY mMr�rw gfs wblecr to tie Workera'Compamaden
Lowe of Cali(omk,�Due 'L '
Applicant �,.. l . ,.n 'k
NOTICE TO APP CAIL after making this CertiRcam of Exemption.You should
mcome Subject ate W s Compensation provisions of the Laha Coda.you menu
O forthwith comply with such provisions a thin permit Nall m deemed rewked.
zy
CONSTRUCTION LENDING AGENCY
[•r Immby a111rm out them is•conslmntim loading agency for the mfirrmana:of
ori > the work(or which this Permit is issued(Sec.7097.Civ.C.)
G Q Lenders Name
U O lander¢Address
1 unity our I have read this application Ana sum thou the AWw kfamation is
ILr•". cancer.1 agree w comply with all city and county on loauu Md rete laws relating m
C) Wilding Wilding construction,and hereby authoria tepmenumws of this city to emaupon that
t27 amw-(We)at a Property(in inspection keep hs
S40
6, (We)agmen:to o Cove,or inspection
keep harmless the City of Cupertino againou
cm liabilities judgmeds,cow sad eapear s which may in My way amen against said City
U z in comequ oto or the granting of this permit.
.. APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT Issued by: Date
SOU REGULATIO S.
/-9_04 Re-roofs
Signuu a! IianVConuumr Dau
HAZARDOUS MATERIALS DISCLOSURE Type of Roof
Will ore applicant or thermic Wilding attmpant arae ohMdle baurdous Material
u defimd by the Cupenim Municipal Cade.Chapmr 9.12.Me am Health and Safety
ale.Section 25532(.)7 All roofs shall be inspected prior to any roofing material being installed.
❑Ya o
Will 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
mfr Woomm.air conuminanm u dcBrcd by We Be,Arse Air Q elly Management all new materials for inspection.
Darim7
❑)an
I have mad dte haurdomma¢rlals requirements underChapterd.95 of the G11(or.
ilia Healm&SA(my Cade,Se9are,255a5.25533 nW 25574.1 uakmwed thuifare Wilding
does ort currendY hew tenML that It u my mmaddlit,m udfy the oaupwt of the
rtyvi Mswhkhm moat —1 jilicamoroccupu¢y. Signature of Applicant Date
��S All roof coverings to be Class"B"or better
Owmr rase Yedgem Data .