04110114 CITY OF CUPERTINO
BUILDING DIVISION PERMIT CI,y,9A OR"
BUILDING I INT ORMeaTItQN
BUIIpING ADDRESS: Pum"N0.4110114
.An PRAR TAP T7)R
WS NAME: PERMITISSUBDATS
GILLIAN RUTTER 11 /9.9. /2004
ONE: - SANY NO. CONTROL NO.
ARCHITECT/ENGINEER: - aun-DiNG PERMIT INFO
BLDG BIF.CT. PtTLUMB M9ECH
t� t� I
�00 LICENSED CONDUCTOR'S DECLARATION .job D ""--"
fi I Wrtby am.dm I an Demand under Proviciam of Chapter 9(cammcneing - Description
p -' -
n� with Section 7MI.f DivisionSof the Buaircas and Protesaivas Code.W my license la
_ in fullrameaedefreer. REMODEL KIT. /BATHRM .(BASEMENT)
b License Class -Lic.p .
E' Dem Contractor - - - -
ARCHnECI•S DECLARATION
I undcnund my plan shell he used as public moorss. �f
s. Licensed Professional r
Oat I am exempt
train
DECLARATION
0 0 i hereby.(Scc that 11. esusin from me CnionsCo License Law for the
',0 0 which following teas;.(Schon 7tra 1.5, 1.a(neas and ere.de seas Code:Any tiny or county )J1 /\
$m which mquim a permit,re cnnamct slut Improve,demolish,t,err repair any steactom - - / // \\ -
y thiormim iensedp hAALM requires Provision Of for such permit Oleuianed w(atemmem - �«
��< thromma wit pSuanttomo of Didomarmeconull.aiame4w(Chapmr9 Sq.Ft. Floor Area {� �ValGation
�^ (eommencin8 with5cetion]000)of DiviainJnf me Buaineasend Profession Code) (Ul/1 n_ y9nnr $40000 -
le',
that M u exempt themfmm and me basis for Ne alleged esempuan Any violmi, of
Section 7071.5 by any applicml for a permit subjects the applicant to J//a civil penalty of APN Number t //4,/ -"JOccupancy Type - - -
ammomlhmfnvehundreddelWs(M). s. , m
❑I.0 owner ofthe property,a my emplaym with wages a,dnbmuW
le comperon, -til �M1\ n
windo the work..namaattanammnanimm�aedaaDemd rareale(ser.]w+.eaama
Required. ections`� V .
and Professional Cade:The Carmelites Liam Law dm not apply to an owner of q p - = -•
property who bulls orimprom Maroon,andwhodm auchwookhimndforlluou8h his `✓
own employm,provided tiro such improvements sm not intended aroRend formle IL
however,the Wilding or improvement is mid within aro year ofcampmtion,the owner.
builder will have W bonder,of proving that he did not build or Improve(or Purpose of
cal.).
1,as miner of the ximpenX am exclusively contracting with licensed contractors to
tmel tiro project(Sec.7044.Business and Profession code:)77th Contractors Li.
case Law dm not apply to an own of pmpeny who build,ser improves Bareon,and,
who contacts for such projects with a contractor(s)licensed pursuant m tine Cantilevers .. ..
License Law.
{]I ex
�j empt under sec ,B&P C for this mason
D.J
WORKER'S COMPENSATION DECLARATION
hereby Latin under penalty of perjury one of me following declandon:
I Mm end will maintain a CanlRmm of Consent to self-imum far Workers Campers.
sation.as Provided for by Section 37M of me labor Code,for the performance of the
work for which this permit is Issued.
❑1 have and will maintain Workers Compenmdon Insurance:n required by Section
3700 of dm labor Cade,for the performance of the wart for which this permit is lasted. _
My Workces Campenadon Insurance tinier and Polity number are: - -
Carrier: Policy No.:
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(This section need not bu completed If the permitIs for one hundred dollars($100)
or less.)
I minify that in the performance of dm work far which this Permit is Island.l shall not
employ any person In any manor se u to bds ono subject in the Workers,Campenatian
Lawlor Cidiromia.Dam
-
Applicant
NOTICE TO APPLICANT.IL after making this Cenillcato of Exemption,you should
become subject to the Workers Compemation provisions of da IoM Code.you must
.JO forthwith comn ply with each provisional or thio persah.ball he domed revoked.
'�.,y CONSTRUCTION LENDING AGENCY
[r 1 hemby olllrm that mem Its convection lending agency for the Pcrformma of
Clithe work far which this covin is Lamed(Sec.3097,Civ.C.)
Leaders Name
25
Z Lenders Address
U0 I cca fy that 1 have and this application and sato that the allow infonaiun is
Is. coma I a8see to comply with JI city and county oNinams and sum law misting in
O U Wilding construction.and hereby authorm representatives of this city mentor upon Ila
W .W\o-mem.rnd pmpeny for Inspection puTums.
tC''i gy (Wer)agree to save,indemnify and keep hamlet the City of Cupenino against
In liabilities,judgments,casts and expenm which may In any way amus against mid City
U z in consequence of the Stations of this Permit
PLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT Issued by: Date
OUfREGULATIONS.
(�= Re-roofs
more rdApplicartlCantaxacter
HAZARDOUS MATERIALS DISCLOSURE Type of Roof
WIII the a Cupertino
or toluic Wilding Oceupmtatom orno t e ti caidan material
sflncd io the Cupertino Municipal Cos,CWptor 9.12,mtl the Hcaith and Safety
de.Section as3xa)7 -• ---All roofs shall be inspected prior to any roofing material being installed.
Yes No
i` Will she applicant ar(alum Wilding oceupam use equipment or devim which If a roof is installed without first obtaining an inspection,I agree to remove
mu hamink iso air conlaminan0 as daMcd by the Bay Arco Air Quality Management all new materials for inspection.
District
❑Yes !m
I hue aalthehaardnusms Hall mquirementsundcr Chaptere,95 ofthc Califtr•
nla Hudd&SafelyCode,SmMu15505,15533 and 25534.1 undconand thaifthe building
dm not currently ham a arrant.that it Is my rtsponihillly to noury the Occupant or dm
nupirementswhichmost In met pdorto..ofeniraateafeca Signature of Applicant Date
/l —ID QL4
cr or authomcd agent Data - - All roof coverings to be Class"B"or better