04030138 CITY OF CUPERTINO
BUILDING DIVISION PERMIT sCONTRACT,ORINFORMATIONNN
BUILDING ADDRESS: PERMIT N0 04030138
10843 MTNT7.TTF DR
OWNER'S NAME: PERMIT ISSUE DATE
AIL NELVIN & PAMELA RABECK
IFE: SANITARY NO. CONTROL NO.
ARCHf1EC(ENGINEER: BUILDING PERMIT INFO
&BLPG ELECT PLUMB MECH
0 0 0
u O LICENSED CONTRACTOR'S DECLARATION
I hmoby union Oat I and licensed under amnsione of Chapter 9(commenting Job Descripti
s, with Section 7MB,of Division 3 of Me Butircss real Pmfcuion,Code.and my license is
^� inicenfomeand cues ADD 993 SQ. FT.
ys(? License Chis Lk.Y 7
n—p Da¢ ARCHITECT'S DECLARATION `o0s
ef , J
Y z I uncarwnJ my plain shell be used u public records
J�U
C y
Licensed Pndcsainnal
Met I am BUILDER DECLARATION
M E 1 naso afrom thin 1 1. ,Business
form the C dins. roc :Anse law prime
i e O following mason.(Sadun IIA L5,Busincu and von.deriens Cnoc:Any city i county y t1
5 B which m9uires a Permit to ems the alkr,improve,dcmelftu a erpair any swctum
prior to its issuan purse requite dmisio cam for such pemn's ience Law
summrnt
xss that W(comma cingwJpurstion7 )previsionn3ofMeenuuessanccnulaw(Chnp¢r9 Sq. Ft. Floor Area Valuation
F$ that he acing with Section add th Division r the
theeged exe and Prorceon.m ions Cedc)or
_ that W u...rept thertfmm and tW buts for MW allegctl exemption.My violation of
Section 7031.5 by my applicant for a pmmh subjects the applicant to a civil penalty of 37032fiffirffier0 0 Occupancy Type
not mom Nan Ove hundred dollars(5500). P y YP
I,uownuofthepmpeny,mmyemployccswithwagesut irmlccompenudon,
will do Ne work,and the swctum is not intended oroRered for sale(Sec.7(N44,Business
and Pmrmimts Code:The Convantm's Liartse law does not apply to son owner or Required Inspections
property who Wilda orimpmms themed.end who daasuch wort himsevor through his
own employes.provided Nat such improvements ma notimmided or offered for sale.If,
however.Ne building or improvement is sold within one year of completion,the ower
Wilder will haus time Wrdm of Proving Nat be did ant Wild or improve for purpose of
sale.).
p901 u owner of Ibe property,inn exclusively contracting with licestsed contractors to
construct the pmject(Sec.7044.Business and Profusions Codc:)The Contractor's Li.
cense law docs not apply to an owner of property who Wilds or improve careen,and,
who contracts for such projects with a conlrumrts)licenced Pursuant to the Convenors
License Law.
❑tun rcpt on S ,B&PC fu .reason
O
WORKER'S COMPENSATION DEC ON
I hereby arBmt under penalty of perjury one of Me fallowing continuations: .
an and will mountain aCaNfnle of Consent to ulf-insure for Workers Comfort,
sation.to provided for by Sttdon 3700 of the Later Code,for Me Performance of Ne
work for which this permit is issued.
❑I haus anal will maintain Workers Compensation Insurer¢,u inquired by Section
37W of the labor Coot,for the performance ofthe work for which this Permit is issued. . .
My Worker's Compensation Insurance carrier and Policy number art:
Carrier. Policy No.: _
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(Thkuction need not be completed if tie Permit is furonc hundred dollars(SIM)
Icss.)
1 certify Mint in the Importance of the,work for which this Permit fs issued,l"I not
employ any person in my mariner an az to become subject o the Workers''Cem,enten lon
"we of California.Date
Applicant
NOTICE TO APPLICANT:If,after making Nis Certificate of Esemption,you should
become subject to Ne Worker's Compensation provisions of the Labor Cede,you most
.J z forthwith comply with such provisions or this permit shall W domed mvnked,
z O CONSTRUCTION LENDING AGENCY
(-+ Ihereby affirm dart them is a comwction lending agency for Me performance or
a the work for which Nis permit i.issued(Sec.3097,Civ,C.)
0.Q Lender's Name
a z lenders Addreas
U Q 1 certify Mt 1 have mad this application and.rete Nat the above information is
E' cormtt i Agra to comply with all city and county o dicari and mute laws missing to
p V Wilding construction,and hereby auhotiu mpoesenutive or this city in enter upon Ne
r WaMvrmcmiencd propcny for inspection puspaxa
F'0. (We)agree to sous,indemnify and keep harmless the City of Cupertino agaitsst
Z incoitiex,judgmenu.granting
riespeMe which mey in any way aceroc against said Ciry
(„)z A PLIC ncc oNDERST NDS this permit. Issued by: Date
APPIIC NDERS NDS AND WILL COMPLY WITH ALL NON-PO NT
U (.ATI % �
a Re-roofs
gnaru lilaandContmctor Date
HAZARDOUS MATERIALS DISCLOSUR Type Of Roof
Will Me applicant or forum building occupant store or hand'-hoodoos material
at cafiued by Oe Cupeniw Municipal Coca.Chapter 9.12.and the Health and Surety
.dc.Section 25532(a)? All roofs shall be inspected prior to any roofing material being installed.
ElYes
Will the applicant or f tum Wilding occupant use equipment or devices which If a roof is installed without first obtaining an inspection,I agree to remove
IR hazardous air contaminants u refined by Ur.Bay Area Air Quality Management all new materials for inspection.
.atria]
❑YesIAF
I hats mad the huardndsmaterials equinamcnu umkrChapmr6.95 of Ne Califor. -
niaHcolth&Safety Cade.Secdms25505,M533md25534.lun&m=dNvif Nc Wilding
dors nom ende 0 hom a cm 4 Nat it k sponsihilit to marry Me occupant or Me
requirements me nr i nr c rm,�r a er. Signature of Applicant Date
o nermamm�riae rant D All roof coverings to be Class "B"or better