05070058 CITY OF CUPERTINO '^ a .cr •siu+nwro-?'
BUILDING DIVISION PERMIT ,;CCONTRACTOR4INFORMATIO
BUIL DING ADDRESS: CLEAR CHOICE u PERMITNO.05070058
10317 MIRA VIS V
OWNER'S NAME: PERMIT ISSUE DATE
CLOUGH DAVID B AND ANNALIS 325 LOS GATOS-SARATOGA RD. 08/02/2005
E: SANITARY NO. CONTROL NO.
(408) 213-1128
ARCHITECT/ENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
C� 0
X00 LICENSED mhanIamRomCONTRACTOR'S derpDECLARATION JobDescri tion
1 hereby affirm than I em!:tinted under provisions of Chapter 9(Commencing -S If;'J�j��� P
£i� wish Section]IXN))afDiviuonlofdu Busfness am Prof iam m li mcu Y (';jy 5x,4 44 n
-P. infullforteandeffa MODEL/RISE STRUC'TURA'L TEAM
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Data Con uanor "
£tf' RCHITECTSDECLARATION
�Ce IundcrwnJ my plans sha1lWuudupuhli<rtcnrds CI .r ��
JyU 7n�
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Licensed professional II'/JJ4a
7 3 OWNER-BUILDER DECLARATION
ftkohh
2 f 1 hereby.(Sm Nal) 1. exempt from the Cssomer o :Any c Law for the
5 m fallowing moron.(Section]!131.5,Business and Profcssiom Code:Any oily or county //„ $65000
which requires a permit ro co mocL alter,improve,demolish,or repair any structures((f, cos
¢i prior to its issuance.also requires the applicant for web permit to file a signed statement -
< that he is licensed pursuant toNcprovisionsoftoContractor'sLicense aw(Chapter9 Sq.Ft. Floor Area `f Valuation
e�a (commencing wish Section 7M)of Division 3 of the Business and Profeuimu Cade)or
.- that he is exempt therefrom and the basis for the alleged exemption.Any violation of
section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of Occupancy Type
not more don five hundred dollars(S500). r P Y YP
I,eowner of IIIc properly,ar my employee wish wage uNeir talc rompenssuon,
willdo thewod,end she nmctum u notinrended oroQcred forsalu(Scc.'IOa4,Business
and Professions Code:The Contractor's Lixme,law does not apply to an owner of Required Inspections
property who bui Ids m improve Nemo n,end w ho does such work himsel f or through his
awn employers,provided Nth such improvements art not intended mortared fwsale.If,
however,the building or improvement Is sold within ooe year of compledon.the owner-
builder will M1aw IW W rden of proving that he did not build or improve fm purpme of
ssk.).
0 1,as owner of the property,am excleivcly conuacung with licansed contractors in
mearrdet Ne project(Sec.]Old,Business and Professions Code:)The Contractor's Li-
came Law docs not apply te an owner of property who Wilds or improve unteon,and
who contracts for such projects with a eon eector(s)licensed personal in the,Contractor's
License Lan
0 l am excmprwnder sec. ,B A P C for Nis rtsson
Do., Data
WORKERS COMPENSATION DECLARATION
1 hereby aRnn under pctulty of perjury one of dm following declarations:
I haw and will reamu rt a Ccrdfimre of Coeem to self-insure for Werece,Compere
sarion,as provided for by Section 3700 of Ne Labor Cock,for the performatnc of the
work for which this permit is issued.
❑1 have and will maintain Workcr's Compensation mpensan Imurmm,as required by Section
J]00 of thc Lator code,for Ne performance of the work for which Nis permit u issoed.
My
and
Caner: �rar� �uolicyNrynum '� 77V
Cartier.♦ G 66 Polity O
CER'fIFl A- Policy
INN FROM WORKERS'
COMPENSATION INSURANCE
(This xcuan need not be completed i f the permit is(ch one hundred dollars(SIM)
or It.)
1 cemfv Not in she performance of the work for which this permit is untied.I shall not
moployany person in any mannersosswb o gtsu 'cert c Workers'Compewtion
Lawn of, ::TgK
ADoi i ant
NOTICE TOAPPLICANT If,after making Nu Omifimte of Exemption,you should
become subject to the Workers Compensation provisions or the labor Code.you most
.J O forthwith comply with such provisions or Nu permit shall be dcoW revoked.
LZ.i M CONSTRUCTION LENDING AGENCY
oz I hereby affirm Nat there it.construction lendingagenc,far the performance of
C' Ne work for which this permit is issued(Sec.3D97,Co,C.)
aW 0 lender's Name
]z Lan ..
Lander:.AM
V Q 1-mfy that 1 have and Ws application and sure Nu the above information is
Is, H co rmt.I afro¢to comply with all city and county ordinances and sate laws relating to
0 V building concoction,and hereby authorise reproxnatives of this city to enter upon use
G ahovcmenuonrd me,properlycosts
for inspection which may
(We)agree to saw,indemnify and keep harmless the City of Cupertino against
t,tU Z in
ants.costsand expenses which may in any way ascetic against said City
(„) ,Z in eomequenee of the gonrin6 of this permit.
^ APPLICANT UNDERSTANDS AND ILL COMPLY ALL ON DINT Issued by:Y' Dale
Re-roofs
Sir....rc of Appli Conuanor are
HAZARDOUS MATERIALS OSURE Type of Roof
WiIINc plicamorfuturc 'Iding uccupan store or hondlcha/afdmismaNtial
u dcOncd by Ne Cupertino Muni al Code,Chapter 9.13,and the Health and Safety
ode.Sauon 25532('?
0 Yea Na All roofs shall be inspected prior to any roofing material being installed.
Will she applicant or future Wilding occupant use equipment or devices which If a roof is installed without first obtaining an inspection,I agree to remove
Al L Dista riz ho
ecs air contaman
ints defined by thc Bay Area Air Quality Management all new materials for inspection.
0 Yes
I have mad the hvardeas marerialsrequircmenu under Chapterh.95 ofdw Califor-
niaFlmhhh Safely Cudc,Smmom355B5,25533und 155]4. unMrsunddearifthc Wilding
doe rmt currcnthy haus a tenant dot it u my rmpo it m Im ily thenccupsot of the
requirements which nods pilar issuanenaf -fiex or Oc mcy.� Signature of Applicant Date
Owner common agent ate All roof coverings to be Class "B"or better G