04020137 CITY O CCUPERTINO
BUILDING DIVISION PERMIThOd � �y^�q,.�^ �„"g
BUILDING ADDRESS: CAROLYN MILLER/BERT FRESC P MT-NG04020137
OWNER'S NAME: PERMIT ISSUE DATE
JE: SANITARYU'/19'1 OL N0.
ARCHITEC(ENGINEER; BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
+IOp LICENSED CONTRACTOR'S DECLARATION O O O O
'r1 Job Description
1 Mmby affirm Out 1 am liaoud under provisions or Chapter 9(commencing
with Switch 70010)of Division 3 ofdw Business and Professions Code.and my license is
in full forte and clfem.
5'�? LlcenuClaa Lk.g REVISION--PATIO
nDau Contractor
ARCHITECTS DECLARATION
1 downward my plans coil W used as public meads
�yU
iGr^ Licensed Professional
5 OWNER-Bxempt R DECLARATION
Commences
I Mmby aRnn Nat 11. accept form an sex Contranora c:Any c ty o for
o O he
following moon,Permit
t 7031.5.Business and Proow,de o demolish,
Code:Any city or county
$ which requires a permit re wren am alar,improve,demolish.w mash any someone
pilar m it caned pursuant
uaogo the lM applicant for suchCon permitContractor's
le se Law(sntemcnt
Q1MtWislianscdpurswnttotWpmviAomofNcContr¢tor'siicevcls..Chapmr9 Sq.F[. Floor Area Valuation
Fg $ (commsis exempt
pth Seniournadd of basis n3 nftWeged cuaand Profcni Mmfc)ar
1� Net he ie 31.5 b Nemirow wad the beer(m On alleged eumpuon.Any violnlon of
Section than I by any applicant fora permit wbJwu the applkat m a civil penalty of 3�bet0 0 Occupancy Type
wt wort than fins hundred dollars(SSOOk
❑I,uowneroftheproperty,ormyempcyces with wagesu Nerwlecompenation.
will do the work and the summure is not intended or offered(orsale(See.7010,Business
and Profession Cada:The Con notes Licenee Law doss not apply m an owner of Required Inspections
property who Wllds or improves Naeem.and who doeaauch work himselfwthrough his
own employees,provided Net such improwmenu em not Intended crolli forale.If.
basvewr,the building or lmpwmentIs sold within one year of completion,the owner.
builder will haus tW burden of proving Nat he did not build or improve for purpose of
UI s owner of the progeny,am exclusively contracting with licensed umn contrin O
construct the project(Sec,7006,Beat..and PrifesSahs Code:)The Cnnracmrs Ll-
ama Law does not pply to an owner of propeny who Wilda or improve Merton,ad,
whoc forurAprojmc ffiacontnctor(s)tkmdpursuantmtbe Contrutoes
Lke w.
❑ e m tootle See BdcPC(Or la n
WO E ' MP SA ON DE�CLA�RATION
1 hereby air=under penalty of perjury ow of)lPIQmwing declarations
KI hoe and will maintain a Certificate of Covent in off-insure for WmsW xCompcn-
sadun,as provided for by Saturn 3700 of On Labor Coe.for the poAormnro of the
work for which this permit is issued.
❑I haus and will maintain Workers Compensation Insurance,as nuf ired by Section
3700 of the Labor Code,for the performance of tW welt for which this permit is issued.
My Workers Compeaation Insurance minor and Polity number am:
Cartier. Policy No.:
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
Mitsoction wed not W compleud if the permit is for one hundroddollan($101))
or 1.)
1 certify Nat in the Performance of the work for which this permit is issued.l shall not
employ anype on y mamoru a to become subject the Workers'Compemalan
Laws of Celife ate
Appl an
NO Y��R�rg�,yy APPLICANT:If,after making this Ccrdftcete of Exemption,you should
Won, YJoel N the Worker's Compensation provisions of On Labor Code,you must
.,O forOwith comply with such provisions or this permit shall W deemed mated.
Z "' CONSTRUCTION LENDING AGENCY
I Wsehy ernnn that then is a construction lending agency for the Performance of '
14 7 die work for which this permit r issued(Sue.3097,Civ.C.)
�W 0 Lenders Name
Z:) z Lender's Address
U0 1 certify Nat I have rad this application and slate that the above information is
U, comm.I egos to comply with all city and county ordinances and ante laws reining to
0 Wilding construction,and hereby auNadmmpoxxcdwiass of Nis city to ower upon the
[37 ahavc(We)awee tesa y(wimnify an lumpIs.
rA (We)agree to cove,indemnify and tech harmless the City of Cupertino id City /
y Iiabilitia,jWgmcnr.costa and expenses which mryin any way acme against aid City
fJ z gLI'C`A19oUNDe1
nso �171'L STALY WITH ALL NO -PO Issued by: Date
T ON
Re-roofs
rtof App UConRDO D.lb
HAZARDOUS MATERIALS DISCLOSURE Type Of ROOF
WIIIy tapplicantorfuture building e.Chaptrune car handle health mauritl
a defined Sc. .h Ne Cupertino Municipd Cade.Chapter 9.13.and the Health end Safety
Code.SOtion 25533(a)1 Y., �"
`,d All roofs shall be inspected prior to any roofing material being installed.
Will the applicant or future building occupant use equipment or devices which If a roof is installed without first obtaining an inspection,I agree to remove
,tha>ardims sir conuminann u defined by NC Bay Arta Air Quality Management all new materials for inspection.
District?
❑Yes pyNu
have mail the baud / aknals requirements;under Chapter 6,95ofIWCalifor-
1"Safctycado.Sw' 505,35533 and 75530.1 undcmao that if lW Wilding
J set currently haw• a it is m mapor(sibility m madly tho we pent n the
re e wk u mel of.Certifiamora g Signature ofApplieant Date
or authoriz degcnt Daw All roof coverings to be Class"B"or better