05060064 CITY OF CUPERTINO +€wes,t• 'rm
BUILDING DIVISION PER UT _41C CiMUTO IN.�F+O�RM�t1TI0"1Vs,�::
BUILDING ADDRESS: PERMIT NO.
05060064
o*081BALIE:11ENDERMST AVE PERMIT ISSUE DATE
SANITARYN LNO.
ARCHITECTIENGINEER; BUILDING PERMIT INFO MECH
BLDG ELECT
56 LICENSED CONTRACTOR'S DECLARATION Job Description
I I hereby af@m Net l am licensed under Provisimu of Chapter 9(mmmercin{
wico Section)D00)of Division 3 of the Business and Prof rstions Code,amimy license is
r in full farm and eff=
13 Llm cCWs Lk-Co.#ractor SFDWL-1 STORY (2226' LIVING SPACE)
i ARCHITECTS DECLARATION GARAGE-454 '
I I unicrstanJ my plans shall M used as public records
I 12/01/05 PERMIT APPL EXTENDED TILL 6/9/06
Licensed Pmfcuioml
3 OWNER-BUILDER DECLARATION
I hereby affkm that L am aempt form the Commodore License law for the
i o following noon.(Section 703 1.5,Business and Professions Code:Any city or county
S which requires a permit to construct,alms,Improve,rismalah,nr repair any structum
;t^ priorw its issuance.also requires the applicant for such permit to file a signed sutemem
ep that he la licensed pursuant to the provisions of the Connectors Ucense Law(Chapter 9 Sq.Ft. Floor Area Valuation
:� (commencing with Section TODD)of Division 3 of NC Business and Profesvnm Code)or
r- dw M is exempt therefrom sand the bask for the alleged exemption.Any violation of
Section 7031.5 by any applicant fora permit subjects the applicant 10•rnll Penalty of APN Number - Occup
AM
not more than Ove hundred dollars(SM. ,
❑I.a owrw of the properly,m my employee with wgu u Nek mle wmpenudon,
will do teworlemul thesuuclum terms Intended oroffeal Resale(Sm. Required Inspections
and Pmfea door onu
Code:The Cmtor's L mme,Law does not apply m m owner of 3 7 5 3 3 0 2 6 . 0 0 q P
propeny who bullds cr Improvesthereon,and who Ones such work himself or through his
Cram employees.Provided coal each WProvemau are mulnueded reoffered foesele,if,
howevv,dee building or improvement k old W thin one year of ampletico.de owner-
Wilda will have she burden of proving Out M did not Wild or Improve for purples,of
ukJ.
❑1,as owner of the Properly,am exclwively conrwAng with licensed contractors to
construct the project(Sec.7014,Business tied professions Code:)7M Conindnr'a U.
cc=Law does not apply to an owner of property who Milds or Improves desmon,and
who contracts far such projects with aconuacwr(z)licensed punwnt M the Contrseloh
License law.
0 I am exempt undm Sec. .B&P C for this reason
Owner' SIJDNjAo ckM/V fCADA21 Goa DA((L/QL
WSRZI PA'S COMPENSATION OECLARATION
1 hereby affirm under penally of perjury one of the following declarumns:
❑I Mve and will malnuin a Cer iEeaafConscnl m self-Wum for WorknM1 Compen-
adue.as Provided for by Seedon 3700 of the labor Code,for de perfomame of the
work for which this permit is issued.
❑I have and will maintain Worker's Compensation Imemanee,as required by Section
3'10!1 of me IaW,Cade.for the performance of the work fur which this permit is lased.
My Worker's Conspeanion Insumnee order and Poli4numbm em:
Center; Policy No.:
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(This sadiron read not becomplead RIM permit kldronehundraddnllus(SI007
Or lea.)
I eenify coat in the performance of the work for which this permit is Issued,I shall not
employ any person In any manners?a�n��orr�a object m cos Workers'Compensation
Laws of Calif99��Ie.Dei^- OL
Applicant_�j[LS I
NOTICE TO APPLICANT:IL Her making this Certificate of Exemption,you should
become subject to the Workers Compensation provisions of the IoM Code,you most
Z foMwilh comply with such provisions or this permit shall be demur remked.
C
CONSTRUCTION LENDING AGENCY
1 hereby alarm that them lea construction undinggeMy for the p rformmce of
We work for which this permit it issued(Sec.3097,Civ.C.)
QLender's Name
Z Lenders Address
Q 1 certify that I have rad this application and sum WI the above information is
carat.I agree to comply with all city and county ordiances and sure laws rekting to
building construction,and hereby aucoodm rep etenuthss of this city to enter upon the
(Ll ahma-mentioned property for Inspection purposes.
(We)agree to on,Indemnify and keep harmleas the City of Cuperlino against
y Iubilitia,judgments.costs and expenses which may in my way accrue against aid City �f / /•�� J
In consequence of the granting of this permit.
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT Issued by: Date
SsVREG IA770NS.��\rs O 2 14 I PI
11 Yuum/C '(� Re-roofs
Signuurt of AppliemVConRDOU - Dau
HAZARDOUS MATERIALS DISCLOSURE Type of Roof
Will the applicant or furore building occupant core or handle h Health
a material
u defined by the Cupertino Municipal Cade.Chapter 9.12,and the Hesith end Safety
cede.Section 25532(.)7
❑Ye ONO All roofs shall be inspected prior to any roofing material being installed.
Will the applicant or future Wilding occupant use equipment or devices which If a roof is installed without first obtaining an inspection,I agree to remove
naardnm air contaminants as dcOncd by the Bay Ara Air Quality Management all new materials for inspection.
Diemen .,i
❑Ya No
I has read the has drus materials requirements under Chapter 6.93 of dte Cabral.
nkHealth&SafctyCodc,Satires ZM5.25533 and 25534.I understand their the Wilding
does not comically haw•tenant.that it 6 my responsibility to notify de aecupmr of dw
rcyulremcnts which msec Morel orwlau°"`�ofl�C�wOcaa of Oce n Signature of Applicant Date
�,r rQ'L'" = "�
Owner or authorixod tot Dam
All roof coverings to be Class "B"or better
a