05080250 CITY OFCUPERTINO LTr�a•«+a+� � ^� °' �� 'f`�"��s" x
BUILDING DIVISION PERMIT ,R4\PJ.�� 0 .a l /y '' �I�/ `
BUILDING ADDRESS: PERMIT NO.05080250
NER'S NAME:
PERMIT ISSUE DATE
STEVE ELICH
HONE: SANITARYNO, CONTROL NO.
ARCHI ECT7CNGINEER: BUILDING PERMIT INFO
Btu PLUMB
MECH
l�
iOp LICENSED CONTRACTOR'S DECLARATION lob Description
sed 1 hereby affirm USA, mO
t 1 am licensed under proviof Chapter 9(comc &g p
fwith Session 70000 of Division 3 oflhe Business and Praf0sm0 Co&,and my license is
+� im(III(am and erccL ADD 646 ' DINING/MSTR SUITE/DINING RM
3i: UcoChLk.g
' nac ia Dam Comracmr BEDROOM/REMODEL BATH/LAUNDRY ROOM
p ARCHITECTS DECLARATION
f uik I understand my plans Small he used u public retards
Jy
s Licensed Professional
b OWNER-BUILDER ER DE CLARATION
1 hereby.(Sere(Section nt 1 I. exempts an the llo lonslCo e:Anse Law for Um
p o following mean. ermitt7(omm Business and ere,demolish.
Code:Any city s county
3$� whish toquim a permit m ennurwt.alar.improve,dcmtd4h,or repair SuY sltoetum '
�iy prior to its issuance.Also requires the applicant fouuch Permit IS Ole a signed statement
Nu he is licensed pursuant m the provisions of do Contractor's License Law(Chapmr9 Sq.Ft. Floor Area Vall i�rp.432
a� (commencing with Section 7000)of Division 3 of the Business and PrefZaona Coke)ar
r3$ Nem
Net he 4 exempt thorm e0vand the basis rte U s Alleged essmption.My NolauW of
Section 7031.5 by airy applicant for a permit Subjects the applicant m a civil penalty of APN Number Occupancy Type
nut mart than me hundred dollars(s5am. 32603027 . 00
0 1.u Owner of the Fop".or my employer with nges As Use sok mmpenudon,
will do the work,and the suuctue 4 ret intended or offered(bur SAM(SOC.7044•Business Required Inspections
mfe
and Pssimu Code The Otherwise,Lx..e Law does m1 apply AS Su Owner of q P
pm pry who buil&O impm+eaa mmeon,and who does such week hiwelf m thmugh his
mvnempiaym,provided that such Improvements Stan cel intended orMend farsale ff.
however,the Wilding or improvement Is sold within one year of compkuon,the mvner-
Wilder will have the burden of proving that he did ret berm or improve for pulp.of
le.).
o
u owner of We prNa rtY.w eaclumvely,mmractUt with licensed mvawmrs to
construct Us prejm(See.7044.Business ad PrOlusiOu Coke)The CoolMors LL
cove raw does aa,apply an an owner or propenY+La Wil&or imPOwa IhereW,and.
who com sets for such projects Mich,eonusmv(a)Bcorued ptmWnt he the CMomm rs
License Law.
❑lam seem .B&Pcf. a
ar Dam 3 O
WORKER'S COMPENSATION DECIaRATION
1 hereby affirm under Penalty of perjury one of the following declardana:
❑1 have and will maintain a Certificates of Consent m self-Insure for Workers Compen.
senors,As provided for by Section 7700 of the lobar Co&.for the pemorm—of the
work for which this permit Is issued.
❑1 hew and will maintain Workers Compensation Insuranco,u required by Section
37M of Um Labor Coke,for the performance of Uta was for which this Form,is Issued.
My Warkers Compensation Insurance sander and Policy number am:
Carder. Polly No.:
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(Ih4sectima need notbecomple ed If tie permit Is form hunWddallan(SIM)
or loss)
I certify dot In the perfo to of work for which this permit 4 Lu41 I not
mnploymy person in W m jest to thew. "Ps
use
Laws df Califomi
APPI
NOTICE TO APPUCAiT.If.after making U&Certificate of Exemption.you should
become Subject he the workers Compensation provisions of Me Labor Coke you man
vJ O forthwith comply with such pwv4lons or W4 permit Wall W deemed revoked.
z= CONSTRUCTION LENDING AGENCY
[..t l hereby Mem that Wert M.emuuucd0 torsi ng aency for tie pemmmatce of
a > Um work for which UM permit 4 Luued(Sec.3097,Cis.C.)
W0 Lenders Name
M
Z Loaders Addreas
U O 1 certify that 1 have red Ws applimumn and sum than chs above IaformstiW is
Dr^
correct.I agree m comply w'IW AlI city and county mdimates,and sum laws totaling to
O SV" building construction,and hereby authorize mpseencedves of this city to cost upon Um
W above-mcaduned pmpany for inspection Purposes
(We)agree m save,III emnify and keep harmless Ute City of Cupertino 88401
y 1iliUes.jud ta.costa and expenses which may in any way acrnc aBimtsaid City
V APPLnICANTe chs STAND(this Pc^nILL COMPLY WITH ALL N N-P01 Issued by: Date d
SOURCE
v 'Re-roofs f� r
Slenmurcof IianUConuanv I I Data
HAZARDOUS MATERIALS DISCLOSURE Type of Roof
Will the applicant of future buding occupant mom or handle hazardous material
AS&fined by the Cupertino Mufti 1 Code,Chapter 9.12.and ftHealth end Safety
.Section 25531(&)? All roofs shall be inspected prior to any roofing material being installed.
i
Oyu a
Will chs applicant or future Wilding oven pan,um,equipment or devices which If a roof IS installed without first obtaining an inspection,I agree to remove
emh bvaNOW air commiV�u� d by Um Bay Area Air Qumhy Management all new materials for inspection.
District?
❑yesI have real chs hazarsquhememwderChapmr&95ofUe CAlifoa
m HaIN cryC .Scairt. 255U3.1337J sent iiS3l.lundcuuM thairdm hdlding
does ter nlly ane Nu my mponsibility m tmdfY Um t of the
mqui anW or m' ache ora cervi mar Signature of Applicant Date
0 3 0
Owner orauthadreda agent Dam All roof coverings to be Class"B"or better