05020184 CITY OF CUPERTINO
BUILDING DIVISION PERMIT Cq 1,TRACTOR TNFOAMATI�ON "''
BUILDING ADDRESS: PERMIT"05020184
Ob5020184
VR'S NAME: PERMIT ISSUE DATE
PHONE: SANITARY A06. �ftOL NO.
ARCHD ECTXNGINEER: BUILDING PERMIT INFO
O O PLUMB MSCHO
a 0 z LICENSED CONTRACTOR'S DECLARATION Job Description
+(j 1 Mreby anum that 1 em Retained under provisions of Chapmr 9(commencing P
nth Sudan 7M)of Division 3 of dm Business atm ProfessionsCode,and my license Is
a, infull force l=i t.f2 S-8 L3 SFDWL-2 STORY (3542 ' LIVING)
jiq Llcensetl¢ l LSD
42-� Date Comments f - - GARAGE 445 ' (CONTR. : MTRAN CONSTRUCTION-06/15/0
(yam- _/ ', AeRc ShallECse DECLARATION
W u I understand
my plane
shall be used u public records
iQ Licensed Professional .
^
OWNER-BUILDER DECLARATION
4 Z I hereby affirm that I am exempt from tin Conuamor's License Law for the
i O o following won.(Section 7031.5.Business and Profanation Code:Any city or"only
$r which requires a Permit In construct.N¢r,wprow.demullat er mpalr any structure
_Zr prior to its Women.also requires due applicant forsuch Permit to rilea signed mammal
< thatbaislicensedpursuanttotheprovisionsofNeCommcmr'slisevclaw(Chapter9 Sq.Ft.Floor Area WWII
ti�600
�$ (commencing with Sudan 7000)of Division 3 of the Business and Professions Code)or
— ttm In,is exempt therefrom and the basis fm the alleged exemption.Any Yi.ladA.of
nSeaaR0h5bbyhmunadlantforaWLittubjeeuNeapplicant macivil penalty of APN Number Occupancy Type
O Luo rofumpmperty,mmydmplayaewlthwgautmtrmle=pewtlon, 37537047 . 00
will do the work.And deawnmeIsnotmmndedararteredPolish:(Sec.7an.Bananeu Rer�uiredIns actions
NMC
d Professions Code:The CAIOYa License Law it=ant apply ill an oml of `I p
property w he wilds ar im prove.th emo n,and who doessuch work nimuu ns Nrongn his
own employees.provided quit such bpaovemenuate n nirm nded oscillated forces,If,
however,the wilding or improvement is sold within on car of eampledon.Ne owner•
builder wiB have the burden of proving Nat an did not wild a Improve for purpose of
ink.).
0 1,As owner of the Property,am exclusively contracting with Ikensed contractors to
,..net Ibe project(Su.7OId,Business And Proessi.N Cade:)The ConnacmYa LI.
cense law does not apply in an owner of prapany who wilds or Improve Merton,ad.
who convects for each projects with a eonarmoKO licensed pursuant in the Conuutoes
License law.
0 l am exempt under Sec. ,B h P C for this won
Data
WORKER'S COMPENSATION DECLARATION
I heroby scrum under peuW ty of perjury ane of the following declandum:
0 1 hew and will mshualin•Cmi fateof Canseel m wlf-0nsurefm WmkeesCampen-
sation.As provided for by Section 3700 of the labor Code,for the performance of the
work for which this permit is issued.
0 I haw end will maintain Worker's Compe um on Insurance,an required by Section
3700 of the Labor Code,forum performance of the work for which this Permit is broad.
My Worker's compnen�adan 1.17���art1er end Policy number-AM:
Cartier. e5T"f1'I rt.Ft�lf+Y Polley No.: t /7—/Sl f
CERTIFICATE OF EXEMP ION FROM WORKERS'
COMPENSATION INSURANCE
(This ratter,need notescomplemd Iftw permit In forced hundred 011.(Sml)
or IC.s)
I certify that in the performance of the work for which this permit Is issued,l shall not
employ any person In any mannerm As to become subject to the Workers'Compemnlon
Laws of Calill mla.Data
Applicant
NOTICE TO APPLICANT:If,alms making this Certlncete of Eaemption,you should
become subject in the Worker's Compensation prorlsions of the Labor Codd,you mnsl
Qz forthwith comply with such provislnns or this Permit shall w deemed invoked.
zN CONSTRUCTION LENDING AGENCY
[—t Ihereby affirm that Nem Is a convection lending Agency for the performance of
ai the work for which Nle permit is issued(See.3097,Civ.C.)
WM to Lendcls Name
z Luder.Address
V Q 1 Certify that I haw rad this application and suite that the show,informNun Is
V, correct.I agme to comply with all city and county ordinances and main laws relating m
0 wilding construction.And hereby auNatlm mpmrnudive of Nis city to enter upon the
W abovcmenumad property fm inspection purposes.
(We)agree to taw,indemnify and kap harmless tea City of Cupertino.0all
cn liabilities,judgments,costs and expenses which may in any way acme against said City
Ionseque�NDI
../�/IPLICAPLY WITH ALL ON POINr Issued by: Date �S. \
Re-roofs
Sigwu fApplicanUConuactar Dau
HAZARDOUS MATERIALS DISCLOSURE Type of Roof
Wit sm appliant or future wilding outipmt nom or Mudie hua douf mmerml
defiuW by the Cupertino Municipal Code.Chapter 9.12.and sac Health and Safely
.
Section 25532(8)?
❑yes All roofs shall be inspected prior to any roofing material being installed.
Will the applicant or crouse Wilding occupant um equipment An Jcvicea which If a roof is installed without first obtaining an inspection,I agree to remove
emit hamosoa air contaminants As defined by Ne Bay Arte Air Quality Matugdmat all new materials for inspection.
District?
❑Yes u
I have read dre bat memmW niquirenrr,u under Clatter6.95 ofdue Califon
niaHalthd,SafctyC Sections25505.25533 and2534,l undenuM Wtifdc wilding
dins not currently he w LNaI yRapaNNllltym.otifyttr¢eYpNter Ne
Ise mxwhich w a .a Ance.is adnate fO Signature of Applicant Date
owners tith.Awd gent 6 (—
Data All roof coverings to be Class"B"or better