04100064 CITY OF CUPERTINO µ °
BUILDING DIVISION PERMIT CONTRA.CTOk INFORMATION
BUILDING ADDRESS: WILLIAM BARTHELL PERMIT ND.04100064
0212 PARIETT RT,
OWNER'S NAME: PERMITLSUE DATE
WILLIAM BA ;114RTHELL NE: SANITARY 0 OL NO.
ARCHGECTMNGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
u
an LICENSED CONTRACTOR'S DECLARATION Job Description
u I bemby afar.that 1 am licensed under provisions mm
of Chapter 9(commencing
p `
n� with Section 7")or Division 3 of NC Business and Professions Code.and my license is -
infullforaandefrmt. GUEST BATHRM REMODEL
j� License Clan Lk.N
Data Contractor
I•i ARCHITECTS DECLARATION
+ei I understand my plana.hell Mused As public oared,
;Qti Licensed Pmfcaional
OWNER-BUILDER DECLARATION
ray 1 herehy art".
that I am exempt from the Contractor,License Law ror the
za following mason,(Section 71131.5.Business and Profession Code:Any city or county
$ which rorrobs.a permit to construct,alcor,improve,demolish,or repair any structure
y Prior to its issuance.also roquim Me applicant for such permit to file a signed comment Valuation
<
Met heislicensed pursuantInthe provisions ofMeCommerce.LiCA.haw(Chase,9 Sq.Ft. Floor Area . . -_
x (commencing with Section 7010)of Division 3 ofd.Bu
usinaenl Professions Code)or
Net he u exempt therefrom and Ne basis for the Alleged exemption.Any violation of
Section 7031,5 by any opplicult for a permit mbjcCU Ne Applicant o a civil penally of 31WN6,0i"cr0 0 Occupancy Type
oat more Nan firs hundred dollars(5500).
❑1,an;owner oftha property,err my employees with wages as Neo ale tompenation,
will do the work and lite sWctuela not intended of offered fonale(Sm.70".Buvtma Required Inspections
and Professions Cade:The Conusemra License Law dean nm apply M an owner of q p
property who bu ilds or impmm thereon,and who does such work himself err through his
awn employees.provided that such improvements Are not Intended or offered for sale If,
however.Nc building or improvement is veld within mm year of Completion.the owner- -�
builder will have dm Wrdcn of proving that ha did not build or Improve for purpose of
Asia.).
❑1,an ower of the property,am exelnsiand canuactin with:)ThRoomed ComaCAS to % -
wnswm the does
(Ser.7014,Base of and property
who Wilds
Code:)The Conuamon. n �S
cera Taw does not apply je an owner a property who budder or improves thereon,And,
who Incense
Lace for projects wINamnu.ctogsl licensed puma.to for
I..A
epee law. ^YY
lam/e cI pl under San
B&PCfor Nis�J�ason /
Ch.U L. Data ID�1ZIdtj
WOR R'S OMPENSATION DECLNI AT ON /
1 hereby%from under Penalty of perjury Ann of Ne following dechMiav: L /
ve and will mJnuin.Certificate of Consent to self-inaum for Workers Compcm
upon,ss provided for by Section 3700 of Ne Labor Code.for the performance of the
work for which this Permit is issued.
❑1 have and will maintain Worker's Compensation Insurance,an required by section
3700 of Ne Labor Code,for Ne performance of Ne work for which this permit 1.issued.
My Worker,Compensation Insurance terrier and Policy number are:
Cartier: Policy No.:
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE r
(Tdssection and not uncompleted title,permllrafmonc hundred dollars(SINB
nr loss)
1 certify Nal in performance of Ne ark for which Nis pertnil u issum,I shall nm
emloantl�non nn .,erra�be'ac-IQ" uiwft Wakn'Cam nudon
lawsofcst1
APPIic�� 4 A&
N017CgJ0 APPLIC :If,afmr mating Nis Ceoineam of Exemption,you should
been abject in Ne Workers Compensation provision of Ne labor Cade,you muss
.J 0 f n"wilh Comply with such provisions or this permit be domed revoked.
Z� CONMUCTION LENDING AGENCY
[—, Iwith,Jnr.Nat Nerch.conslructi.kndingagcm.T rot Ne rerrormura of
a>
the work for which this permit Is issued(sec.3097,Civ.C.) _
W A Landers Nunn
IY lander,Add.
U 0 1 anlfy that 1 have mad this application Ann sum Nat Ne above information is
W F CMTCC,L I agree to comply with JI city Nd county oNlnNtea and male taws relating to
O V building convection,And hereby authorize repreantstives of this city m emu upon Ne
W ebova-.cntiuned property for insrecdon purpoam.
(We)agree to an.indemnify and keep harmless the City of Cupcnino against
r;y fq
liabilities,Judgments,casts and expenses which may in any my,cmc against said City /
U 7 in consequence of the granting of this permit.
r7 APPLICANT UNDERSTANDS A WILL COMPLY WITH AL4 NON-POINT Issued by: Date
OURC ATT`NC y�t¢'
66 !! Re-roofs
rgnamm of ApplicamMonuactor Date Type of Roof
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future building occupier store or handle humdous mamdJ
a defined by the Cupertino Municipal Code.Chapter 9.13,and the Health and Safely
Code,Section 35533(.)7 All roofs shall be inspected prior to any roofing material being installed.
[D You P5No
Will the applicant or mturc building occupant use equipment or devices which If a roof is installed without first obtaining an inspection,I agree t0 remove
mit hazmdnua air connminuts as dcfjmd by Ne Bay Ana Air Quality Management all new materials for inspection.
Dimict7
Yu 411.
I have mal Ure hazardous ma erialarequirromms under Chapmr6.95 of Ne Califno
nix Health&SJnyCode.Seeusxu 75505,35533 and 35534.1 undcnund dulifthe Wilding
dap rtol cunemly heve a tonal dal it u my responsihility M nodry the amupat of Ne
nuhnouldRicivihichmUSlMm plow, me ahCatincatoofoe�lpayyy Signature of Applicant Date
/1 '�4 l0/11 Ofj'
�r armMmivad. Cm c All roof coverings to be Class "B"or better