05020044 TY OF CUPERTINO �^-r<s.bs/d:a si+.vavld' kx'/^ r '°s&
BUILDING DIVISION PERMIT .,CONTRACTORINFOR ATION
BUILDING ADDRESS: PERMIT Ncb 5 0 2 0 0 4 4
W IT NER'S NAME: PERMISSUE DATE
ONE: SAN By NO. CONTROL NO.
ARCHIEC(ENGINEER: BUIIDING PERMIT INFO
BLDG ELECT PLUMB MECH
0 0 0 0
�oo LICENSED CONTRACTOR'SOEConsof CON
1 hereby )of TNI1amfbe Bu undernd Profession
Chapter9(commencing Job Description
n� withllfomm]t3(Io)of Division Sof be Bassam...and Profeuiom Cade.and mylicemeis /�
inrmlram,Wer ,r3,a4 Q DECK REPAIR/HAND RAIL/ RESTUCCO�//
Liccneo, us Lle.11"ye-r V
n�SO Dam �O cmuseuh, T — U
Sod ARCHITECTS DECLARATION ��� �pAj®
4P unci unJ my plans shall be T'S as public records OO
�yV
4 Licensed Professional n
g Am I a OWNER-BUILDER R DECLARATION ♦ �(JD
d Ct 0 1 Wrehy.Seco Nal I e.5 exempt from the Contractor's License law for the O /lJ� /n/ppp p 1J s
i c O following mason.(Section](131.5,Business and w.di
ionr Code:Any city or county �(
which requires a pcnnit W conslrucL alter,improv.Ocma1LN.or repair any structure \�111//f kkk o
FZiPrior m PCO
61 issuance,also ocipims the applicant for such Peiuo rile a signed statementAxa that hcis;licensed pursuant tothe tenvisiouofthe Contractor's UmnxLaw(Chapter 9 Sq.Ft. Floor Area uhValbgtton-1
,4h§ (Commencing with Section 7")of Division 3 or the Business and Professions Code)or u v({�1
dist he is exempt therefrom and the basis for the alleged esempdon.Any violation of
Section 7031.5 by any applicant for a permit subjects the applicant W a civil penalty of
not mom than fin hundred dollars(6500). 31464M46elO 0 Occupancy Type
❑1,As own"of the property,a my employees with wages As dmu sole compensation,
will do the woh,and the structure 4 not intended or offered for sale(Sec.7044,Business
and Pmfessiou Code:The ContrxWra License law does not appy W an owner of Required Inspections
propenyw W builds or improves themon,and whodxssuch work himself or through his
own employees,provided that such improvements arc notimen led or offered forsace.If.
however.Ne Wilding ru improwmant is sold within one year of improve
omm a for the
Wilder will will have Ne W Wen of proving that W did not Wild or impmw for purpose of
sale.).
❑1,as owner of Ne yMpeny.am eaduively contracting with licensed conoace rs W
tomtnect the Project(Sec.7014.Business and Rofcasiou Cos:)The Convector's U.
cease law dos not appy W an owner of propeny who Wilds or improv thereon,and.
who contracts for such projects with a contractor(s)licensed pursuant W the Con ractues
License Law.
O I am exempt under Sec. ,B de,P C for Nis mason
er —DOC
WORKER'S COMPENSATION DECLARATION
I hereby affirm under penalty of perjury one of the following dmlentions:
v Iham and will maintain a CcrOrime,ofCmtsenuo elf-insure for Workers Compco
setion,As provided for by Section 37M of the Labor Code.for be performance of the
work for which Nis permit is issued.
1 have and will maintain Workers Compensmion Insurance,u required by Section
7 ofthclabor Code,imum perform CA of the work forwhich this permit u issued.
My Worke\jaCyp�rpenyy(ti/yt ce c 'm and Policy n —�
Came'..�.LSJ= Policy No.:. _
CERTIPICA OF EXEMPION FROM WORKERS'
COMPENSATION INSURANCE
(Thu acmion need not hicompleWd if the permit Isforone hundred dollars(SIM)
or kssJ
1 ecnifv that in the performance of the work for which his permit u issued.l shall not
employ anyperson to any manner At,As W become subject W the Workets'Compensation
Laws of California.No,
Applicant
NOTICE TO APPLICANT:IL after making this Certificate of Exemption,you should
become mbject W he Workers COMFCnsalton Previsions of the Iahnr Code,you must
.JO foMwith comply with such provisions or this permit Nall W deemed revoked.
Z55 CONSTRUCTION LENDING AGENCY
[— I hereby affirm Nat Vert is a cmamosson lending agency for the Performancea
ai the work for which this permit u issued(Sec.309'1,Civ.C.)
1 Lender's Name
]z Lendss
Lender's Addre
U Q 1 certify that I have read Nis application and rode,Net Ne show information u
gg,F torte"I agree W comply with all city and County onditumes and sum laws relating W
0 building Construction.and hereby audosire mproamutiv or this city to color upon the
V.1 show es juoned proPeny(Ad inspection puryoms
F+y (We)agree to saw,indemnify and keep harmless the City of Cupenino agaim,
h in
of t5,tuuiAdd of this Fe which may in anyway accmc vgaiut said City
U z A APPLICANT
of im UNDERSTANDS
of this permit.
SOP:T RF GUIN•AA'gOSTANDS AND WILL COMPLY WITH ALL NON POINT Issued by: Date
x _ i7 Oyr2S� Re-roofs
Sgnuum of Applman ontraetty�— Date
HAZARDOUS MATERIALS DISCLOSURE Type of Roof
Will due applicant or future Wilding occupant Alone or him4le haaardous material
u to Med by IM Cupenlno Municipal Code.Chapter 9.12,and the Health and Safety
dc.Sccuon25532(a)? All roofs shall be inspected prior to any roofing material being installed.
❑Yes TIO
r\ Will We. licant or future holding aces ant nsc If a roof is installed without first obtaining an inspection,I agree to remove
PP g e equipment of Mann which Qi
aMOYs air comm�inanu u defined by the gay Area Air Quality Managcmcnt all new materials for inspection.
rim?
YesI have read the hicardusmaberiau myuimmenuunderChaplor6.95orthe Caliror-C41ke&SafnYCO4,Sees=25505.25533 and 25534.1 undcrsund thatifne Wilding
not eturoin,haw•tennt Nat it u my responsibility W notify the oecupant Of themcnts whichm mettior W issuance of a Ccri Kam cupenry. Signature ofApplicant Date
or Authorized agent D,e, Al I roof coverings to be Class 'B"or better