04030140 CITY OF CUPERTINO '
BUILDING DIVISION PERMIT XONTRACTORRIINFORMATION
BUILDING ADDRESS: PERMIT NO04030140 4030140
102 5 M
R'S NAME: PERMTT ISSUE DATE
LESLIE M FOWLER
NE: SANITARY A. CONTROL NO.
ARCHITECT/ENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
0 0 0
aft 0 0 LICENSED I a CONnsed under provisions DECLARATION Job �®
mF 1 heuby affirm Nes I am ONTRA under SDELLA of Chapter 9(commencing
2`uj with Section 70110)of Division 3 of the Business end Profcssioru Code.and my license is
^34; inform=and elect. REMODEL (E) SUN ROOM
S E2a License Class Lic.R
Date GrnDEC JUL -& 1005
44 ARCHITECTS DECLARATION
y k i l understood my plana"I be used as public record
D01 UAL®
GG
Licensed hereby Professional ■mak pOk s �,�s.
5 OWNER-BUILDER DECLARATION �■f�Jtp{1Ij[lJt�p�p-q- q
EOOI hereby affirm that 11. exempt from the fexti Co :Any taw for the
O o which following titin..(Section RD I.S,Business and nye,de oli Cade:Any city or county
$ which its i us s Permit re coowcL alter,improve,demolish,ri mash any statement
prior m its issontt.alto pursuant
to the she applicant for such permit to file a sighed stetemcnt
g�g�<
that beiscinif wit pSectio70theM)provisions of the Contractor'ssinesLlttnulsw(Chapter Code)
Sq. Ft. Floor Area Valuation
d�$ (hattlan a exempt
Section and the
Division r of lM Businsemptio and .Any vi Cs,on of
that be u exempt therefrom and dm hose far the alleged exemption.Any violation of
Section 7031.5 by airy applicant fm a permit subjects the applicant to a civil penalty of 3�a�`Qn� ane iBer0 0 Occupancy Type
not mom man five hundred dollam(M). P Y YP
❑1,ss owttou of the Property,of my employees with wages as their ole compenuuon,
will do the work and me uructuu is cart intended or offered for sale(Sec.7044,Business
and Professions Cod:The Conhacmrs License law does act apply to an owner of Required Inspections
property who builds or improves merman,and whodces suchworkhireulf ormrough his
own amployces,Provided that such improvements are not intended croffemd forsalm IL
however,the building or orphanhood is old within one year of complcuon,me owner-
builder will have the burden of playing that be did not build or impmw fa puling,of
sale.).
1,u owner of Ute p Nny,am escloively cm=ting with licensed ttnwcmss w
Without me project(Sec.7044,Business and professions Cade:)The Contractors Li.
come law doer not apply to an owner of Property who build or improves thought,and.
who c.nsrarm for such projects with a contractor(s)licensed pursuant to the Contractors
License law.
[jI am exemps under See ,B&PCf rte'
Date K e
WORKER'SCO PENSATIONOECLARATPN
1 hereby Mout under penalty of perjury arc of the following dcclanuou:
I have and will maintain•CeruOcam of Consent to self-hour,for WorloesCompen-
sation,as provided far by Section 3700 of the Labor Code.for the performance of use
work for which this permit is issued.
❑1 have and will maintain Workers Compensation Insuruce,as;unrolled by Section
3700.f the labor Code,for the performance of dte wort fa which this permit is issued.
My Workers Compensation lot.. a carrier and Policy number are:
Cartier. Policy No.:
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(Thu section need not Wcomplemd if the permit Is throne hundred dollars(SIM)
or tessJ
I unify that in the pcormaran¢of the work fm which this Permit u issued.I shall nuc
employ any person in any manner sou to become subject o the Workers Compensation
Law.of California.Dau
Applicant
NOTICE TO APPLICANT:IL after making this Ceninexte of Exemption,you should
become subject b the Wadi Compeoasio,Provisions of the Labor Code,you most
.JO runhwith comply with such provisions r this Permit shall Ito deemed revoked.
z h CONSTRUCTION LENDING AGENCY
[-w hereby Mom thou fu iso consuatim lending agony Tor me perrommmc of
f� > the walk fur which this permit i.issued(Sec.3097.Civ.C.)
fa70 Lander'a Name
=z Lenders Address
U Q 1 certify that 1 haw mad mu application and sale that the show ofnalmd"u
D. P contact.119M m comply with all city and county oNimp ces and state laws totaling to
0U building construction.and totally autborim mpreunmives hfmis city to on=upon the
ahme-mentioned PmPcny for inspection which may
F y (We)agree to save,indemnify and keep harmless the City or Cupertino agaiol ��
Z inconsequence
oiuesunce of theranting ng of thisscas pewhicn maythany way accmc against said City
U Z APPLI rue T UNDERSTA140S A D WILL Issued by: Date
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT
SOURCE gEGULATIONS.
l��.a.Y 1. dt"etti IIS irlf Re-roofs __T
Sigho fie ofAp�lwanvcom set., `T
HAZARDOUS MATERIALS DISCLOSURE_ Type of Roof
Will the applicant or future building occupant store or handle huardoo onward -
defined by the Cupertino Munitlpal Cede.Chapter 9.12,and the Htalth and safely
-Alilkc,Sccue,25532(x)? \, All roofs shall be inspected prior to any roofing material being installed.
Yes f7lNo
TTT, If a roof is installed without first obtainingan inspection,I agree to remove
Will the applicant or future building occupant esu equipment or Jcviva which P
emit tailanho. it omumionts u dcfimd by the Bay Asea Air Quality Management all new materials for inspection.
District'
❑Ycs ®Nu
I have read the Ward "crisis"crisis requirements under Chapter 6.95 ofine Califon
nix Health&Safety Code,sections 25N15.25533 and 25534.1 undersold that if the building
data trot currently Mw a rant,mat is u my maponsihility to Imufy Ih oecuPant of me
rty 're .ts hien m..vbemt Prior to issumlccofa Cmallcue of - psncy.�jl}/ vfy`ignature of Applicant Date
Owner or authorized agent Dam ` I `-P All roof coverings to be Class "B"or better