05020072 CITY OF CUPERTINO �=�
BUILDING DIVISION PERMIT CONTRACT FORMATION"
I�NFORMATIO,N
BUILDING ADDRESS: PERMIT NO.ROBERT HORSIE 05020072
OWNER'S NAME: PERMn ISSUE DATE
NE: - SANITARY OL NO.
ARCHITECTPENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
l� 0
LOp
LICENSEDCONTRACTOR'S
under
SDECons of CON
wp 1 bcrsby affirm that 1 am f the
under and
Preons ofC outs. 9(commencing lob Description
<W with llto=adaffec Division Jof tint Busincssand Pmfessino CaM.and mylicea¢u
PON
in full farce and effect
S gjZ Liccnsechar Lb.N REVISION--IN HOUSE USE ONLY
Dam DpmDEC NO NEW PERMIT ISSUED/ ORIG. 403090153
As shall E use DECLARATION
?w U I understand my plans shall W used u public records
Licensed Professional
p 3 OWNER-BUILDER DECLARATION
3y I hereby al Not I am exempt from the Contractors License Law for the
a O following reason.(Swdlun 7031.5,Business and Prefessiuru Code:My city or county
$V which requires a permit to cnnsruct,alter.impose,dcmnlish,nr mpair any swctmc
Fiy prior to its issuance,also requires the applicant for such Perming file a signed statement
iso thatWislicensedpimosottothePovisiauafNeConuazwfsliec.Law(Chapter9 Sq.Ft. Floor Area Valuatif 81115
m t- (commencing with section 7f0))of Division J of the Business and Professions Code)or
W$_ that he is exempt tha.l.and the basis for the alleged exemption.Any violation of
section 7031.5 by any applicant for a permit subjects the applicant w a civil penalty of APN Number Occupancy Type
not more than five hundred dollars(8500). p Y YP
❑I,nowofinepmpeny,mmycmployemwithwagnastheirmleeoopenudon, 35705002 . 00
will do the work and the structure is net intended oroffered forsale(Sac.7014,Business
and Professions Code:The Conuecwfs License Law does oat apply as an owner of Required Inspections
property who builds orimproves thereon,and whodas such workhimself ord ough his
ownemploym,provided 04,
pranchem I.semenuartf,year tete npIstmd for rolan. \
however,the building or iimprovement is sold within one year of completion,me owner-
builder will Mrc the Widen of proving mat he tlitl not Wild or improve for Puryose of
sob.).
I,u owner of the property.am udusively contracting with littnsed cdnmctors to
lonsvuct Bm project(Sec.7060.Busirvu and Pofrs ions Cade:)The Contractors U.
scow law docs not apply to in owner of property who Wilds or improv dsrson,and V
who contracts for such pmjecu with a cdnoactnr(s)licensed pursuant to the Contractors
Licenm law.
❑lam «. ,B&PC for this n �J
Ownu Dam 3 U d
OR 'S COMPENSATION DECLARATION
aRrm under perW ty of perjury one of the following declaratipm:
I bare and will maintain a Canlfreate of Consent w self-insum for WorkersCompen-
saion,M provided for by Section 3700 of the labor Code,for the performance of the
work for which Nis permit is issued.
❑1 have and will maintain Workers Compensation Insurance.ar tequimd by Section
37W of the Labor Code,for the performance of Ne were forwhich this permit is isomd.
My Workcra Compensation Insurance carrier and Policy number am:
Carrier. Policy No.: _
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(This section need not kcamplewd if the Permit is fmmmhundred dollars($10p)
or It.)
1 certify that in the perfuvmnee of thc work for which this Permit is issued.1 shall not
employ any person in any manner so as in he voe subject to the Workers Compem mbw
Laws of Califooia.Date
Applicant
NONCE TO APPLICANT.If,after making this Certificate of Exemption,you should
become subject w the Workch Compensmlon prownwm of the Lahr Code,you must
.J O foMwith comply with such provisions or this Permit shall tic de
e emd erevoked.
Zy CONSTRUCTION LENDING AGENCY
I hereby ofon that there it.construction lendiogagenry for the Performance of
FL Ne work for which this permit is issued(Sec.3097.Ci,C.)
Lenders Name
z lender's Address
U Q 1 certify that 1 bare read this application and state that Ne aWn information is
Uy P correct.I agree to comply with all city and county ordinances and slate laws relating to
0 V building construction,and hereby authodm mpmsimudoms of this city to enter upon the
above-mentioned
mescos for inspection purpowhich may
H a (We)agree to save,indemnify and keep harmless the City of Cupertino agairsst
V Z Iiaconsequenc enu.c rase and fthispswblch may in any way eecmc against Mid City
in conuquene nnf of this permit.
" APPLIC DS AND WILL COMPLY WITH ALL NON-POINT Issued by: Date
S ]!REG
Signs' car optic V Ondrambor z Re-roofs p m
HAZARDOARDOUS MATERIALS DISCLOSURE Type of Roof
Will the Cupertino tore building o¢upaptr 9,12.handlh eardand Safety U dented io the Cupertino Municipal Calc.Chapter 9.13,and the Health and Safety
cwe,sreYnnzss3z(a77 yy All roofs shall be inspected prior to any roofing material being installed.
�Yci is No
l( If a roof is installed without first obtainingan inspection,I agree to remove
Will the applicant or(atom building ottupant use equipment or Jcviccs which p
.cit haMrol air Inntaminams as defined by the Bay Amo Air oust ity Management all new materials for inspection.
ismict7
❑Yes �Nu
I have mad the haardrws mawriaisrequiremsems under Chapmr695 of the Califor-
niaHcalth&SxfctyCedaSecti 25105.75533 soul n534.1 understand has ifds building
docs notc rcacon that it is my res'nairlity to notify the occupant of the
mqui cmv cls t riorloissuanccofaCertiBcateofOccaancy. Signature of Applicant Date
U
ownerora thori>e a or p All roof coverings to be Class "B"or better