05100173 CTY OF CUPERTINO xa IAL_ _
cONTR�CId [NOR10BUILDING DIVISION PERMIT "pit
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BUILDINO ADDRESS: PERMIT NO.0 510 017 3
7635 ORANGE BLOSSOM DR
ER'S NAME: PERMITISSIIEDATE
CHARLIE FERNG 02/23/2006
NE: SANITARY NO, CONTROL NO.
ARCHITECT/ENGINEER: BUILDING PERMITINFO
BLDG BLECT PLUMB MECH
30o LICENSED CONTRACTOR'S DECLARATION Job Description
i� I hereby aHlrm that 1 am licensed under provisions M Chapter 9(commencing
with Section 70)0)ofDivislon 3 of the Business and ProfeMiu"Code,and my license is
n in full fame and affect. ADD-LIVING/DINING/DEN 654 '
License Clan Lic.a
b Dam Contractor REMODEL-ENTIRE HOUSE 1, 6021
e ARCHITECTS DECLARATION
u 1 understand my plans&hall he used as public records
yc Licensed Professional
OWNER-BUILDER DECLARATION
i 1 hereby affirm that I am exempt from the Contractor's License Law for the
O O following mason.(Section 7031.5,Basin=and Pmfeasion Code:Any city or county
$ which requires a Pcrmlt to construct,slier,improve,demolish.or repair any structure
—Z Sa prior In iss Woman.also acquires the applicant for such permit so file a signed statement
F that he is licensed Preseason Wdr,prevision ofthe Contractor's License Law(Chapter 9 Sq.Ft.Floor Area Valuation
y $
(comm acing m and the basis for the alleged exemption.Any violaBoncing with Section 7000)of Division 3 ofthe Business and Prefnsiou Code)or $301598
.. OMI he t&exempt thomfron of
Section 7031.5 by any applicant for a permit subjects Me applicant W a civil penalty of APN Number Occupancy Type
not more than five hundred dollen(M),
❑L as owner of the property,or my employes with wages u Iheir=to rompensnlon,
will do the work and the&"More is atimendedoraQered forsale(Sec.7041 Business Required Inspections
and Prefes&ons Cade:The Contractor's License Law docs Coel apply M an owner of q p
progeny who builds or improv theraan,and who does much work himsel f or through his
ownemployen,provided thatueh improvements aro nut intended Creamed ferule.If.
however,the building or Improvement is sold within one year of mmple0on.the owner.
builder will have dm burden of proving that he did wt build or improve for purpose of
sal.).
❑1.as owner of Me property,am exclus vely containing with licensed contractors to
Consumer Me project(Bea.7041,Business and Profession Cade:)The Contractor's Li.
cense Law does not apply to an owner of property who Wilda or improves Merton,and
who contracts for such projects with amntractor(s)licensed pursuant to the Contractor'.
License Law.
❑1 am exempt under" .B ds P C for da rcuon
m Dam
0 CE 5 CO ENS\TION DECLARATION ,
1 hereby a t under Pe ty of perjury ane of dm foltowing I&ehe.$:
I baro and will m& &ditomof Comxenlloulf-inu"forWorke.compen-
xetion,u provided fm by Secdan 3700 of the Labor Code,for the performance of Me
work for which this permit l iuue4
❑1 Mw:and will maintain Worker's Compensation Insurance.a required by Section
3700 of the Labor Code,fes Me performance of the work for which this Permit is issued.
My Warker'e Compensation Instance artier and Polity number re:
e
Carver: Policy No.:
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(This section need not becomplewd if the Permit isforane hundred dollars($1001
or less.)
I certify Mat in the performance of Mc work far which this permit u issued.I shall not
employ any Pcraon in any man m bdc-me Y@m d
ket rc Workcri C�mn
pea0on
Laws of Ca ifomie.Dae / 1(
APPllcant —�
NOTICE TO APPLIC �1,,a r akin➢ Ccn ujC of Esp prion.you should
become subject to rho ricer'sComponsati proem of the Thor Code,you mum
.JO foMwith camp to Pron"'a"or apermluh&I be deems&mwkcd.
y CON N LENDING AGENCY
F+ I bemby affirm Mat Mem I..Concoction lending agency far Me performance of
ISi'tom Me work for which this Permit is i&ad(Sec.3097.Civ.C.)
QLenders None
z Leader',Address
J C 1 certify Mat I have mad this application and stato that the ahove information is
F coma I agra to comply with&1 city and county on inances and outs lave mlating to
0 U building construction.and hereby authorixe representatives of this city to enter upon the
`,G➢) above-mentioned property for Inspection purposes.
[G^ (We)agree in save,indemnify and keep harmless the City of Cupertino against
In Ilabilida,judgments,costa and expenot which may In any way am=against mid City
U in consequence of the Swung of this permit. ^-�
G APPLICANT U ER NDS WILL COMPLY WITH AL NON-POINT Issued by: Date �G ^2 G
SOURCE A S.
Re-roofs
Si or p dConus r Dam
HAZA OUSMATERIALStAmeoURE Type of Roof
the applicant utoro building occuputatorc or handle haardous motorial
as dented b CuPMJ o Municipal Code,Chapter 9.13,and the Health tad Safety
e'secBan All roofs shall be inspected prior to any roofing material being installed.
❑Ya ON.
Will the applicant or future building eccupant use equipment or devices which If a'roof is installed without first obtaining an inspection,I agree to remove
It haaraous air contaminants a defied by the Bay Area Air Quality Management all new materials for inspection.
strict?
❑Yet ❑No
I have mad the haardouseratedels requirements underChapter 6,95 of the Califor-
MaHcalMk SafctyCodc,ScMiom25505,25533 and 25531,1 understand thatifthc building
Jan nal curtenllY he a ton L Nat it responsibility to no01'Y rite acupsnl of dm
mqui, 'u"w 'c uin met prior truceofaccreficsWof up&my. Signature of Applicant Date
owner P a Masa" Dam All roof coverings to be Class"B"or better