03090153 CITY OF CUPERTINO
BUILDING DIVISION PERMIT5 CONTRACTOR INFORMATION. �.'
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BUILDING ADDRESS: PERMIT N00 3 0 9 0 1 5 3
10545 MIRA VISTA AV
OWNER'S NAME: PERMIT LSUE DATE
XSIE ROBERT J 11/17/2003
PrE: SANITARY NO. CONTROL NO.
st y
ARCHITECT/ENGINEER: c aUILDING PERMIT INFO
BLDG ELECT PLUMBtT Mn
0 0
+0❑❑0 fOLICENSEOCONTRACTOR'SDECLARATION JbDescri tion
e z 1 hereby arm that I am de
licensed under provisions of Chapter 9(commencino
g p
e< with Section 76pi Division 3 of the Business and Prnfcsslnne Code,and my Been.is
a, in full force andcfmm' ADD 604 SQ. FT.
jq? License Class Lic.R
Date Contractor
ARCHnLCT'S DECLARATION
1 trwour and my plans shall W used as public records
SaU
e
Licensed Pmfcasionel
OWNER-BUILDER DECLARATION
a1 hereby.(firm that 11. exempt from the Contractor's Co e:Any c Low for the r�
0 o following moss.(Semites ID7 s r t,after, and vat,de Professions Code:Any city nr county N9 kat
$_ which requires a permit m construct,alms improve.JemnluA nr repair any mm�um A $73000
°ZS^ priorto its issuance.also requires the applicant for such permit to file a signed statement
¢Qss< that he is licensed pursuant m the provisions of the Contractors License Law(Chapter 9 Sq.Ft. Floor Area Valuation
.+Fro (commencing with Section 7000)of Division 3 of the B.Oncas and Pmfcssions Code)or
$ Net he Is exempt therefrom and the basis for the allcgcd esemption.Any Antedon of fit" nn
Section 7031.5 by any applicant for a perch subjects the applicant to a civil penalty of BI Cl'4 tj Q1try Occupancy Type
not more Nan five hundred dollars(SSW). vvv
0 I,u owner of the property,m my employees with wages u their sole compensation, ftQ A111 a;
will do the work.and Ne swcwm is not intended ora@red faneIt,(Sec.7041,Businesswh
a�,
and Pro essions Code:The Contractor's Liana Law does not apply le.n owner of a Ina
property who build.or Improves thereon,and who does such work himaHor through his
ownemployms.providcd that such improvements arenotimended meRered Intrude.If.
however,the building or improvement Is sold within one rat orcompletion,the owner.
builder will have the burden of proving that he did not Wild or Improve for purpose of
ale J.
•1,as owner of the propeny,am exclusively contracting with licensed contractors to
couuoct the project(Sec.7D11.Business and Pmfessiou Code:)The Conuacmr's Lt.
cans Lew docs not apply to an owner of property who Wilds or improves(human.and
who contracts for such projects with a comnclorEd licensed pursuant to the ContractoM1
License Law.
0lsum exe .,Sec. ,Bk PC Prde exon
Owner Date 1(1(7k 73
If W K SAnON DECLARATIO
Z. e.b tees under penally of perjury ON of ON roll owi tlxleatun.:
"—� I have and will maintain a Certificate or Consent to ar-In1n(s Workers Compete
satlon,an pmvided for by Section 37W of the Letter Cade,for the performance of the
weak for which thi.permit is issued.
0 1 ban and will maintain Worker's Compensation bsunna.u required by Section
3700 of rhe IeWr Code,for On,performance of the work for which this permit is issued.
My Workers Compensation InsunOce canis and Policy number art:
Cartier, Policy No.:
CERTIFICATE OF EXEMP ION FROM WORKERS'
COMPENSATION INSURANCE
(This action need not M compmed INN Permit is for one hundred dollars S HKE
m Icons.)
I canary that in the performance of IN work for which this Permit u issued.I shall not
employ any person in any mannersn as or become subject o ll¢Workers'Compecnlon
Laws of California.Dam
Applicant
NOTICE TO APPLICANT:If.after making this Certificate of Exemption,you should
become subject m the Workers CamNMtion provision of the IeWr Code.you muss
0 O forthwith amply with such proviunru m this Permit shall W domed revoked.
Z tiCONSTRUCTION LENDING AGENCY
I hereby affirm that then 1$1 COMOrN inn lending agency for the Performance of
the work for which this pmcit is issued(Sce,3(97,Ci,.C) '
Q Under's Name
5 z Lenders Addoss
V Q 1 cenify that I ban reed this application aha sum that the above information is
jy correct.l agree he comply with all city and county oNimnces and rue laws nclning to
p building coesWclion,and hereby authorim mpm]enulivel of this city to enter upon the
W Novo-mcntiuned property for inspection purposes.
(We)agree le ave,indemnify and keep hucless the City of Cupertino again
Taq II.bHft1m;.judgmen1U,cossaw..rU,n.es whichmayinanywayaccmeagaimtaid Clly
V 7 In cansequcncc of the gXS'
f hin permit �(1
'7 APPLICANT DEAND WILL COMPLY WITH ALL NON-P INT Issued by: D U
B° LZ
I rllr��a3
" turG f "HAZARDOUS MATERIALS DISCLOSURE TicTT Type of Roof
Will the applicant tar future building occupant amro Or handle hazardous material
u dellncd by the Cupertino Municipal Code,Chapter 9.11,and the Health and Safety
ode.Section 25532(a)7 All roofs shall be inspected prior to any roofing material being installed.
Tlir� yer
Will the applicant or public building Occupant use equipment or devices which If a roof is installed without first obtaining an inspection,I agree to remove
auNous oar contsmimna u dcMcd by the Bay Area Air Quality Management all new materials for inspection.
LX y/Nu
lhave mar the Wnrdnusmaterials myviremcw under Chapter 6.95o(tM Glifnr•
dnai.oHanoubt currently
urrentlyy hCenndca,S¢anewnn demit u rryireswrisah3ilail.y1ummm,l'y tubtheaaaifuthPe.mWt oilfdithnge
.qui muSIW ipriortuiuumceof&Ccnlficae."" ey
Signature of Applicant Date
I
11
0 er Monti 1 Dm
All roof coverings to be Class"B" or better