08040057CITY OF CUPERTINO
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BUILDING DIVISION PERMIT
pACUNTRACT(,I2Ik'4..L'fATION
BUl RESS:
LD].�1 G D��
PERMrr NO.
NOVEMBER DR
TBD — TO BE DETERMINED
08040057
NEWS NAME:
PERMIT ISSUE DAIS
SANITARY NO, CONTROL NO.
ARCHTfER/ENGINEER:
BUILDING PERMIT INFO
BLDG ELECT PLUMS MECH
O O O O
LICENSED CONTRACTOR'S DECLARATION
Chapter 9
Job Description
1 Wseby affirm that 1 an licensed under provisions of (commencing
with Swtion7MIJ)afD,Vmoa3afNCBusiness and PraleaziomCadc.aMan, license b
ADD MSTBDRM, BTH, OFC, ENTR&COVRD FRNT PRCH RMDL
in full fora Nd drat
LianmClasa Lic.is
MBDRM, MBTH, KTCHN&FAM RM
Dam Contrxur
ARCHITECTS DECLARATION
I understand my Plan shall W used az public mcoNa
Licensed Professional
OWNER -BUILDER DECLARATION
1 hereby allim, Nat I am exempt farm Me Contractors License Law far Mm
t fallowing means. (Section 7(n I.S. Bushrou, and Professions Cc&: Any city or county
which mal a permit m emmsmom alun.. impmva, demolish, of repair my structure
! priarto its issuance. aom mhos. the applicwt for such permit m file a signed mammon,
Man la, islicemcd the Cwtracmrs License law
Sq. Ft. Floor Area
Valuation
puraantm provisions or the Chapter
(commencing with Section )000) of Division 3 of Me, Business and Professions Code) or
$100000
I
_
• that he is exempt therefrom and the bass for the alleged eaempoan. My violation of
36216024 Number
Occupancy T'pe
Section 7031.5 by any applicant far a permit subjects Ne applicant to a civil penalty of
w, moa dnBsehundreddallasODM.
0 I• us owner of Ne property, a my employe. with wages u their aole compensation,
will do Me work. and Ne mmctba It lmtinmmded or offered forsake (Sec. M44. Business
Required Inspections
and Profeasiom Cods, The Contractors License law don act apply m an owns of
property who builds or i mpmses Nemo., and who does such work himself or through his
awn employees, provided Mut such improvements as not intended or oRcad for sale. If,
however. Ne Wilding or Impeavemnl is sold within am year of completion, the owner.
builder will have Mm tarda of proving Nat W did not build w imparve for Purpose of
sats.).
1, as owner of Mm Property, am exclusively conaacting with licensed coauatora is
comuucl the Project (Sec. 7014, Business and Pmfcssio s Cade:) The Coamacmra U.
come Law does ant appy to an owxr of property, who Wilds or improv thereon, and.
who carouses for such projects with a eomlaclogs) licensed pursuant to IW Contranar's
IJame law.
❑lama .8For n
�b
1 mby affirm r Porosity of perjury as of the following declanuom:
01he d anuina Cenificam of Canmtoself-inamfw Workers Compen-
YI(on. us Provided for by Samoan 37M of has labor Code. for Mm perfarmwa of the
work for which this permit is imued
0 I have and will maintain Wmlmea Compensation Imuran, as required by Scc,ion
37Wafthe labor Code, fords, per(orman of Ute woh forwhirb Nbpeen is inroad.
My Workers Compensation huusna carrier and Policy number am:
Cartier. Policy No.:
CERTIFICATE OF EMPTION FROM WOR(ERS'
COMPENSATION INSURANCE
rn,ssection held notthe completed dome permit Isfaone hundaddollan (5100)
or less)
la" v Nat in Ne mfarman of Mm work for which isperanh s imbed. I shall no
employ anyppeeLLssoos in any twner aazm beconc sebje tat Varkers'Ca pe Mon
lawn of Giifordl
ConiRcamf emp,ion,youshould
became sub' m Ne We a Campcusauon provialous of L IoW, Code you am-
'
foMwith ply with such provisions or Ns perms, shall W dccnmd rewkcd.
CONMUC71ON LENDING AGENCY
I he ,m, Nat thea is a cammbctinn lending agewy for Me performance of
the warts fur which Ms permit s issued (Sec. 3197, Civ. C.)
undoes Name
Lenders Address
I «miry Man have rod ors applicvion and sum Nm Ila above information is
cmma I agrca to comply with all city and county ordinances and sum laws missing to
Wilding comwcWn. anal hereby
`
mthorim represenuOv of Ns city to enter open Me
aWve-mwu propmy far iespou ies puryems
(Ws,) agree m save, indemnify and keep m
p imics Me City of Cupertino against
gem
liabilities. Judgement. costsandexpemm which may in anyway acme against said City
' in <onsegmlae of Bunuon6 of this permit
Mm
APPLICANT UNDERAND WILL COMPLY ALL NON -P INT
'
Issued by:
SANDS
O
1
Date �C
Re -roofs
signaba car °am
phcan o^l'ac0U5
MATERIALS DISCL E
Type of Roof
11 Ns, cep ' w, w fuwm Wilding wcupwlmore or lundle harudous material
ea dmfs d b upeNw Municipal Cade- Chapter 9.11. and the Health and Safety
.sem es zss3z(.)?
❑Yn VN.
All roofs shall be inspected prior to any roofing material being installed.
Will the Applicant or future Wilding occu ant lose a w devices which
IN B P a
If a roof is installed without first obtainingan inspection, I agree to remove
Pe
emit havardnaz air cwuminwts us defined by Mm Bay Area Air Quality Managcmcnl
Air Qu
all new materials for inspection.
Dbu w?
❑Yes Cpl Nu
I have retl M¢ incumbents motorists ocMiamcn s under Clspier6.95ofthe Cable.
nastiest" aty S=d m253D5.25533wd25534.lwdcrsunditif Me Wilding
don no' :y have a o-^,^4 Lha s it my responolMiity m y Mm ozupm, rate
,
requiremcntswhcn Wm amiabwanraC
Signature of Applicant Date
All roof coverings to be Class'A:a' or better
Owner al sore ,ed, t Da