06050047 CITY OF CUPERTINO
BUILDING DIVISION PERMITCUI�iTRAiCT''(1RTI�CI (�Rb'TATYQf�i '
yx5,2� ^mwx ..^S.r, "b§r ' at*a-8h
BUILDING ADDRESS: GOLDEN STATE BUILDERS PERMITNO.06050047
21475 MILLARD LA
OWNER'S NAME: PERMIT ISSUE DATE
SCHROTENBOER RONALD B AND MARY148 E VIRGINIA ST QS/12/9006
Et - SANITARY NO. CONTROL NO.
4082871221
ARCHITECTIENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
00 LICENSED CONTRACTOR'S DECLARATION lob Description
! i bunchy dorm that l m licensed under Provisions of ChaPW 9 wron neing p
sZt ' with Smaon71100)of DivWan 7 ofmc Budnm and Profcedou Cade.vul my lkense is
I.fail Iowa,mdtrremREVISION. ORIGINAL PERMIT# 06050047
f g z Lkinme a Lk.a
F 11
Dam CanUxbr4A�r 4—A 'y-
ARCHITECTS DECLA1u77oN GOLDEN STATE BUILDERS RENEWED BL 5/5/06
f I understand my plants Nall be used u public records
u
�✓�t; Licensed professional
-„� OWNER-BUIIDER DECLARATION
<>: I Wrcby aflm thin I am eeempt from the Contractor's License Law for the
:no following won.(Saban 7113 1.5,Business and Pmfeseiau Cade:Any city or county
59 M which mquiroe a permit in cnnwuee alar.Improve,demnliah,or afar any swmum
_z i• prim to is iuuanec.also acquires the spplieant for well permit in ale signed asamem
pp < that he Is Haunted pursuant to the provisions of we Contractor's License law(Chapter9 FI. TIOOC Area Valuation
Y�0 rema: ngwia SeWon7000)d Dividan7ofda Business ftfetsiam Codc)m ,$0
y $
them he is esempl therefrom and the basis for me Wlcied csempllon.My violation of
Section 7071.5 by any applicant far a permit subjects the applicant an a civil mostly of ATN Number Occupancy Type -
m mart than live hundred dollars(5500).
❑I,u owner of me property,m my mploym wins mgm u reek won compemdm.
win do Newark and mxauw
ena Mtaundatimcffered rarsam(Sec.lou.Business Required Inspections
tad Pnfeadou Code:The Contractors License Law does not apply w owner Of ownof q p
property be builds IXimprovde n.wd whodatatachwork blaselformmugh his
own=play=,provided thalmeh improvemws m not muccumd"offered for rye B.
however.me drilling or improvement is veld within am year of mmplWan,the ownv-
builder .will have the burden of proving that he did not Mid IX Improve fm purpose of
won.).
❑1,as owner of the property,am uclusively comaw ing with licensed mnvxmn le
construct the pmjea(Sec.7044,Business and Profession Cade:)The Conausar's Li-
cense law does cont apply to an awner of property who builds or Improv daemon.W.
who emmeta for such pmjecu with ammnctora)Maned purnam a the Containers '
License Law.
❑I am uempt under Sec ,B B PC for was mum
Das
WORKERS COMPENSATION DECLARATION
Or 1 hereby affair under penally of perjury om of the following declaruim:
❑I MIs and will for by
aCenil7M of the LAW se ds.for fa WarkNS Cmpcn-
sWm, r provided(IX mi Sada]100 d me labor Cade,fm ave performance,of Ua
wont for which this permit is issued.
❑I have and will maintain Workers Compensation Insurance,as required by Semon
77W of the labor Code,fm as performance of the work for which ms peau a axed.
My Workers Comppee nm rant¢munnor all Policy nmbtt m:
Carrier. �7&7* X policy No.:! &7� 9 eoe
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE a
(This smlm need rot becmpkhed If ew Penult Is faroc Madrid dollars($100)
or less.)
1 certify that in the perform-acc of the work for which this permit is issued,("I m
employ any person in soy manmcrsn a in became subject as me Worke s'CompmuWon
Lam of Califomia.Dam
Applicant
NOTICE TO APPLICANT.If,later making m4 CeNlcaa of Exemption.you should
become subject to the Workers Compensation provisions of the Labor Code you mus
.J O forthwith comply with such pmvirW duc
an or this marl,shall chemical n,.ked.
?0CONSTRUCTION LENDING AGENCY
[–, 1 hereby tall data mem is a construction lending agenry,for me pe formana of
the work for which this pemit is issued(Sec.7097,Civ.C.)
QLenders Name
z Landers Addw
U C I certify that 1 have and this application and sera and the abort information a
(y,F correct.1118100 to comply with all city and county aNinances and sate lam mating m
�O building construction.and hereby aumodn teprcxnmiv of this city to enter upon me
above mentioned property far mareeaon purposes
F+ (We)agme to save.indemnify and kap hanmlm the City of Cupcnma agalmt
a.y y Iiabilidm judgments,costs aW expenses which may in soy my accrue Miami[said City
U z in consegmrce of the iranting of this Permit.
.. APPLICANT UNDERSTANCIAND WIL COMPLY WITH ALL NON-POINT Issued by: Date
SOURCE REGULATIONS
Re-roofs
Signature of AppUaHAZARDOU °ito Type of Roof
HAZARDOUS MATERIALS LUOM in
WIl the applicant m form building e.Chantuarc m sunk h eallon metrial
u deaMd DY Use Cupertino Municipal Code.Chapter 9.13,nal the Herm and Sdcq
sic,Section 35553(a)7 All roofs shall be inspected prior to any roofing material being installed.
❑Yes
Will me applicant or future Wilding acupam use equipment or devices which If a roof is installed without first obtaining an inspection,I agree to remove
emit hnardam air eonuminans u dcOmd by rot Bay Arca Air Quality Managemcm all new materials for inspection.
District?
❑Yes �Nu
I hum and the me ardnns mmrialsaquimm ens under .Cluparti.95ofine Califon
riallcalth@Sdmy6 doSaWons25M5.25577and25574.1mdcntsndamKft Willing
Jas rot currcnl Y ve a tows thin it s m liability to Mary dae aceupant of the
requirements Kam noranissuanceof�Ccnifemeaf ry• Signature of Applicant Date
Owner or authorized agent — All roof coverings to be Class"B”or better