05100072 CITY OF CUPERTINO
BUILDING DIVISION PERMITCON„TRACTQRI1�tFRMATIO
BUILDING ADDRESS: S . P . CASPARY CONSTRUCTION, PE 0.05100072
10430 MILLER AVE
WS NAME: PERMIT ISSUE DATE
CAROLYN BOWKER 1765 PARADISE
?HONE:
SANITARY NO. CONTROL NO.
(408) 779-1389
ARCHITEC(ENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
LICENSED CONTRACTOR'S DECLARATION Ib Description
e C 1 hereby affirm that 1 am N Hamm under provisions of C(upur 9(mmmexOBSCrIP
ing
i with Section]IXMI)af Divi Sof the Business aM Pra cions Coda dmylzcnseu
±ta„ inmummeaMcrrmt. REVISION-TRUSS CALCS
)nK License n. pfd1 �o
Dam Tn�n Ytaw IN HOUSE ONLY-NO NEW PERMIT
shallECs DECLARATION ORIG #05070051
I
as
I understand my plain shall he used u public records
hyU
e G Licensed Pmfcstianal
3 OWNER-BUILDER DECLARATION
E I hc¢hy offirm that I am ucmpt from the Camra use.License Law for the
0 O following main.(Section]031.5,Buair¢ss and Professions Coda:My city at county
$ which requires a permit to construct.alcor.Improve,dcmoliN,or ropes,any smmm.
priorm iuiuuarme.alsomquimstheapplimitarxchpermi0ofthcasigmdsutement
' at he is licensed pursuant to the provisions of Ne Contractor's Liecnx Law(chapter 9 Sq.Ft. Floor Area Valuation
YFC Commencing with Section 7000)of Division 3 of the Business and Pnefshimu Cadel or
y
that be is exempt abandons and Ne beau for the alleged uemptim.My violation of 0
Section 7031.5 by airy applicant for a permit subjects the applicant to a civil penalty of APN Number Occupancy Type
nor mom dun five hundred dalism,W00). P y yP
I,se ownm of the propsry,Or my employees with wage as their x4 compensation,
will do the wok and the swcuu e u not intended or offered for sale(Sec.7041,Business
and Professions Cade:The Conuacmr',License Law docs tel apply N an owner of _ Required Inspections
property who builds orimpmwcs thereon,andwho doessuds work himatc for through his
awnemploy .pmvideditt=himprowemmuarenaint,MM orofferMforsalell
Wfidearawill ehbauveilddiung bru rdreto of pmmoving
is that
within one Wild or completion,Ne owner- y
k did not build or improve for purpose of
0❑1. V
L u owner ej ct property.704,B exclusivelyeand contracting with BamW mnuaclon m
innstm a the pmjea(See]s Business;arta ProftstrionsWild.
Cadei The Comrecmrh U. y `
roue law dare..,apply m an iw a onuwwnywho build,or impmat thereon,and. / v
who c e Law.fw such PmXN with a mnuanm(s)1'meued punuanl m lk Convdaah
E]Ian Law.
1 oro exempt under Sec ,B A P C for this roasen "C /
v Dau J�
WORKER'S COMPENSATION DECLARATION J
1 hereby affirm under penalty of perjury ons of the following declda0ou:
❑1 baro and will maintain a Certificate of Couentm self-insure forWorker'sCompcn-
cation,a provided for by Section 3700 of the Lebon Cade.for the performance of one
work for which this permit is issued.
❑1 have anal will maintain Worker's Compensation Insurance,as,mquired by Section
3700 of the labor Code,for the Ndo mum of Ne work for which this permit u issued
My Worker's Compensation Info carom and Policy number .lU I�U
Carrier. D J '� Paliry Na.: t I /7
CERT( GTE OFEXEMPDONFROMWORKER3'
COMPENSATION INSURANCE
(This orlon need nmWcomplemd if the Permit is(monehundred doBan(1100)
or leu)
1 certify that in the performance of the work for which this permit is Letter,1 shall not
employ any perm in any mannerse at to become subject to the Warton,'Compensation
Laws of Ca1(fomia Dem
Applicant
NOTICE TO APPLICANT:IL after making this Certificate of Exemption,you should
become subject m Ne Worker's Compensation Provisions Of the Labor CMe.you mon
.J O forthwith comply with such pmvidans or Nu permit shall he deemed mated.
Z 5; CONSTRUCTION LENDING AGENCY
Ihcreby affirm that Nem u a construction kMing agency for the performance of
a the work for which roes permit u issued(Sec.3(y9'1,Civ.C.)
6Wi Q Under$Namc
z Tender's Adchess
U Q 1 certify that l have read this tt'lictuum and sum thd dm shove irdomution u
LL conem I agree to comply with all city and county ordinances and sum laws muting to
c Wilding construction.and hereby authurim repreunutiws of this city to enter upon the
above-mentioned property for inspection pmposes
F 1 (we)agree On save,i demnify and keep hdm4a the Gly of Cupertino against .
II liabilities,judgments.cents and No.which may in any way acme against end City
V Z in consequence of the graining of this permit.
'—' APLI UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT Issued by: Date
S R -R U TIONS.
VJ
Sig to o(ARe-roofs
p it. nux r Dam
H OUS MATERIALS DISCLOSURE Type of Roof
Will lM applicant or forum building omuput scam or handle hamdcus material
dented by the Cupertino Municipal Cock.Chapter 9.11.and Ne Health and Safety
.Oroe tion as3z(a)] O All roofs shall be inspected prior to any roofing material being installed.
Will the applicant or umm building Occupant use equipment or devices which If a roof is installed without first obtaining an inspection,I agree to remove
emit hazardous air contaminants at refined by ase Bay Area Air Quality Management all new materials for inspection.
Dwri<t] /
❑Yu fTYFfu
1 have read Ne hosediu smatedala requi,emenu under Cyupter G93 a(Ne Califm.
nice HeslN&Safety Cadc.Secvoru15S03.23531aM23534.1 umkrsuM thaifde building
deer t N nt have•tenant.that it u my responsibility m notify the occupant of the
mqut m c mustbcma 'or m' uanmof,CcrtificamolOccuury. Signature of Applicant Date
o n o ,aNad><a agent Date All roof coverings to be Class"B"or better