04060108 CITY OF CUPERTINO /-� s +gam♦a' +°ry� y ` �` 1�7
BUILDING DIVISION PERMa`y\-+® 11[141k' �CL � � ,
BUILDING ADDRESS: - PERMIT NQ.4 0 6 010 8 -
ER'S NAME: PERMITISSUEDATE
JAMES KLAPPROTH
PHONE: AUG SANITARY NO. CONTROL NO.
ARCHITECT/ENGINEER: BUILDING PERMIT INFO
MLLANQ� BLDG ELECT PLUMB MECH
�� 0 0 (�
poo LICENSED CONTRACTOR'S DECLARATION
C w I hereby off m Nat 1 am licensed under provisions of Chapter 9(commencing .IOb Description
w '.on 7'y
rDivision3of NCB ince and Pr r miam Cmimmdmylicenmis
"My imm�mreean mm. Oc"aLq O REPAIR SHOWER (FUNGAS DAMAGE)
i Liccnsc as Lic.#
� � Dale camaemr J '^� CONTRACTOR: THRASHER TERMITE & PEST CONTROL #17
AACHITECI-S OECLARPT
�+CC I understand my plans shall be used a public records
?aU
3pt; Licensed P..beat...I
OWNER-exempt ram Ce Conte ON
a 1 hereby reaso .(Susn that 11. exempt from the Contractor's a Liccnsc Law for the
00 whfollich acquires
permit
in co str t,Business and Profcmmoli Codc:Anyepaicity nr county
K$w which rets Issu a permit re CtinswcL far,improve,h ermit t fi Rash any structustatement F Z j, that hor o its ceased pursuant
nt to the pre applicant mefor sucContractors
rc toot Lice s Law
atammcm
that licensed pumuin7 the of Division
meehe Buaztoesnd Professions
(C Code)
Sq.Ft. Floor Area Valua l55(]
$ that he is(commencingwithSection IDnd)of Drearis n 3 of the cited exempt on.Any
viol Me)or
s
that he is exempt therefrom and da bazu for me flcgcd exemption.Any violation of
Section 7031,5 by any applicant for a pennil subjects the applicant to a civil penalty of APN Number Occu anC e
not mare than five hundred dollars($500). P y 'J p
O1,as owner of the property,or my employees with wages m their sole compensation, 326'39032 . 00
will do me work,end me structure is not intended or offered for sale(Sec.7094,Business
end Professions Code:The Canneries License Law does not apply to an owner of Required Inspections
property who buildsorireprovea thercon,and who doessuch work himaelformrough his
own employees,provided that such improvements arc at imended or oQered far sale.If.
however,as building or improvement is said within one year of completion,me owner.
builder will have me burden of proving that he did oat build or improve for purpose of
sate.). 1
O 1,as owner of the property,am exclusively contracting with licensed contractors to
ccesuuct the project(Sec.7094,Business and Professions Code:)The Contractors Li-
cense Law does riot apply to an owner of property who builds or improves thereon,and
who contracts for such projects with a contmcfr(a)licensed pursuant to are Conmectaes
License Law.
O 1 cert exempt under Sec. .B&P C for this mason
net Date
WORKER'S COMPENSATION DECLARATION
1 hereby afRrm under penalty of perjury one of the following deeleratiam:
O 1 have and will maintain a Certificate of Consent to self-insure for Worker's Cocaine-
work for whick this
this by genion 3]00 of me Labor Code,for me performance of the
permit is issued.
O I have and will maintain Worker's Compensation Insurance,as required by Section
3700 ofine Labor Code,for the performance of the work for which this permit is issued. -
My Worker's Com nnalion bases nmter and Policy no
Comer �L...I7 polity No: —�_ +
CERTIFICAT60F EXEMP170N FR M- ORKERS'
VVV COMPENSATION INSURANCE
(This section need not be completed if the permit is far one hundred di(SIM)
nr less.)
I cenify that in the performance of the work for which this permit is issued,1 shell not
employ,any person in any manner so as in become subject to the Workeri Compensation
Lows of California.Dam
Applicant
NOTICE TO APPLICANT:If,after making this Ceaifteam of Exemption,you should
became subject to the Worker's Compensation provisions of the lahnr Code,you must -
Qp forthwith comply with such pmvisions or this permit shall be doomed revoked. '
„z„ i
CONSTRUCTION LENDINGAGENCY
Iher which rte marmite issued(Seetion lending agency lar me perfurmana of
ai M the work fur which this permit is issued(Sec.3097,Civ.CJ
{✓a Q F,mdees Name
=z Lendees Adtlress
U Q I certify that I have mad this application and marc mat the above information is
LL F' Cann[against to comply with all city and county ordinances and sate laws relating to
0 t.1 building construction,and hereby authmie mpmsenmiivcs of this city to enter upon the
W L11mm-mentioned property for inspection purposes.
a (We)agree in save,indemnify and keep hetmlesn the City of Cupertino against
h liabilities,judgments.costs and expenses which may in any way seem against aid City
U Z, in canuquence of the granting a(this permit.
�-^ APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT Issued by: Date
S EGULATIONS.
6 e 0 Re-roofs
Si t rcof Applicant/Connctor am
HAZARDOUS MATERIALS DISCL SU Type of Roof
i 71011 are applicant or future building occupant stare or handle h emmus material
es defined by the Cupertino Municipal Code,Chapter 9.12,and the Health and Safety
dr.Section 25532(x)?
a ?❑Ya p"O All roofs shall be inspected prior to any roofing material being installed.
Will the applicant or future building occupant use aquip..at car devicas which. -If a roof is installed without first obtaining an inspection,I agree to remove
emit hanardous air contaminants as dellmd by the Bay Area Air Quality Management all new materials for inspection.
District? J
Oyes
Ihave&Safmad t mode sections25aerialsm33and554,1undamnas under hepad that ofine Calbi
ding
nieHealth&Safety Coda,Sections iti 2my and25339.1 to entry to ati(mehoofing
Jas not curtcnrly hove a tenant that it is my responsihiliry m noul'y da occupant of the
mquimmcssw a bcmctpficru,,x,mmcora CcniOca a(Occu�ney. Signature of Applicant Dat
�Ct.t Co
Or car suffimacd agent Dpa All roof coverings to be Class "B"or better
- WOOD DESTROYIN•F. 3TS AND ORGANISMS I•I, CTION REPORT
uilding No. Street, City, Zip Date of Inspection No. of Pages
10360 Phar Lap Drive, Cupertino, CA, 95014 06/11/04 6
THRASHER TERMITE & PEST CONTROL
17427 Farley Road West
Los Gatos, CA 95030-3308
Ph: (408) 354-9944 Fax: (408) 395-7934
nn
Firm Registration No. PR 0240 Report No. 26966 w
Ordered By: I Off
Property Owner Party o Interest: 010 [H6 T .
Remax Real Estate-Carolyn Miller Mr. and Mrs. Klapproth Cornerstone Title
19200 Stevens Creek Blvd #210 10360 Phar Lap Drive 100-A Drakes Lnding Road #120
Cupertino CA 95014 Cupertino CA 95014 Greenbrae CA 94904
C-21 Alpha - Fred Martin
2160 S. Bascom Avenue
Campbell CA 95008
COMPLETE REPORT ❑ LIMITED REPORT ❑ SUPPLEMENTAL REPORT, M REINSPECTION REPORT ❑
General Description: Inspection Teg Posted:
A Supplemental Report pertaining to the master bathroom Subarea
shower and floor area only. Other Togs Posted:
Thrasher...04/28/04
An inspection has been made of the structure(s) shown on the diagram in accordance with the Structural Pest Control Act.
Detached porches, detached steps, detached decks and any other structures not on the' diagram were not inspected.
Subterranean Termites ❑ Drywood Termites ❑ Fungus/Dryrot 29 Other Findings Further Inspection
any of above boxes are checked, it indicates that there were visible problems in accessible areas: Read the report for details on checked items.
ED
DIAGRAM NOT 111,11q �t��1�
TO SCALE 1u1
OF CUPEONO
~11,11116 ArWor
0V TMD C t obi s i I c3111L01�
cEwR �
1N P�DRDAN
. GyPl��NO
DAT. on
' sPectti
S1G7 sat of Pians andat a1lGmas aaaltetabanm
ape kept o e e anY chanBasatmissl
1av�oi t e ytthoot wig of all .
n5Pin.0.. do ac,
°he b�tldstnp g o�yistP a° of,to be,
NDO ah0� 8 �e 8nY PCOY1�141F R 0 N T
• aPPCaval p0 JmOlz a of a to
,s aay GtNI
Inspected B Miguel Torres OPR 9921
P Y License No. Signature
You are entitled to obtain copies of all reports and completion notices an this property reported to the Structural Pest c-ontr*olard ring the preceeding two years.
To obtain copies contact: Structural Pest Control Board, 1418 Howe Avenue, suite 18, Sacramento, California 95825-3204.
NOTE: Questions or problems concerning the above report should be directed to the manager of the company. Unresolved questions or problems with services
performed may be directed to the Structural Pest Control Board at(916) 561-8708, (800)737-8188 or www.pestboard.ca.gov. 43M-41 (Rev. 10101)
2nd PAGE OF STANDARD A ECT10N REPORT ON PROPERTY AT:
• 10360 Phar Lap Drive, Cupertino, CA, 95014 06/11/04 26966
BUILDING NO. STREET, CITY, STATE, ZIP INSPECTION DATE REPORT NO.
NOTICE: The Structural Pest Control Board encourages competitive business
practices among registered companies. Reports on this structure prepared by
various registered companies should list the same findings (i.e. termite
infestations, termite damage, fungus damage, etc.) . However, recommendations
to correct these findings may vary from company to company. Therefore, you
have a right to seek a second opinion.
This is a Supplemental Report to our company report #26746 dated 04/28/04.
NOTE: This property was not inspected for the presence or absence of health
related molds or fungi. By California law we are neither qualified,
authorized nor licensed to inspect for health related molds or fungi. If you
desire information about the presence or absence of health related molds,
you should contact an industrial hygienist.
The following areas were not inspected, as indicated in Section #1990
paragraph (J) of the Structural Pest Control Act and Rules and Regulations:
Furnished interiors, inaccessible attics, insulated attics, and portions
thereof; the interior of hollow walls; spaces between a floor or porch deck
and the ceiling or soffit below; stall showers over finished ceilings; such
structural segments as porte cocheres, enclosed bay windows, buttresses and
• similar areas to which there is no access without defacing or tearing out
lumber, masonry and finished work, built-in cabinet work; floor beneath
coverings, areas where storage conditions or locks make inspection
impractical. A further inspection is recommeanded at any/all inaccessible
areas, please contact our office for any additional information.
THRASHER TERMITE AND PEST CONTROL is not a licensed roofing firm. If any
interested party desires further information, a licensed roofer should be
consulted.
NOTE: IF REQUESTED BY THE PERSON ORDERING THIS REPORT, A REINSPECTION OF THE
STRUCTURE WILL BE MADE. THIS REQUEST MUST BE WITHIN FOUR MONTHS OF THE DATE
OF THIS REPORT AND THERE WILL BE A FEE.
RECE ED
JUN 14 2404
CITY OF CUPERTINO
BUILDING DEPARTMENT
THRASHER TERMITE & PEST CONTROL---License No. PR 0240
3rd PAGE OF STANDARD P ._.ECTION REPORT ON PROPERTY AT:
• 10360 Phar Lap Drive, Cupertino, CA, 95014 06/11/04 26966
BUILDING NO. STREET, CITY, STATE, ZIP INSPECTION DATE REPORT NO.
This is a separated report and is defined as Section 1 and Section 2
conditions that are evident as of the date of this inspection.
SECTION 1 - Infestations, infections a E ate
listed below contain items where there t estation,
infection or conditions that have resulted in or from estation or
infection found on the date of this inspection. Ir 2:n
SECTION 2 - Adverse conditions where nos M� tions were
noted at this time. The findings listed w o ons deemed
likely to lead to infestation or infect WPA\1je 18411 RNTvidence of
such was found on the date of this inspection. "��1V6'
Our company cannot assume any responsibility for conditions existing in
these areas unless an authorization for repair, replacement or further
inspection of these areas is made in writing.
SUBSTRUCTURE AREA:
` Item 1H: REGARDING ITEM #lE FROM REPORT #26746.
FINDING: We opened the area below the master bathroom shower. Our intention
was to remove and replace the damage from below the shower area. However, at
• the time of our repairs we found further damage. There is fungus damage
going under the shower pan and under the bathroom tile floor. Fungus damage
exists to the 4" x 6" rim joist, floor joist, 211 x 4" wall plate, wall
framing and to the sheetrock backing. It is impractical to remove all of the
damage without disturbing the shower.
RECOMMENDATION: Remove the shower enclosure and save it. Remove the complete
existing stall shower to include the shower pan, tile and sheetrock. Remove
the damaged wood members and check for concealed damage. If no further
damage, is found we will treat the exposed and adjacent areas with a
fungicide. New materials will be replaced/reinforced as needed. Reinstall
the same shower pan, properly plumbed. Install a vinyl strip around the
top/base of the shower pan. Install new greenrock at the shower walls,
taping and sealing all voids. Install new ceramic tile throughout the
complete shower. The new tile will be set close joint, in a mortar base. The
tile will be installed up to the ceiling. If any further damage is found
another Supplemental Report will be issued.
****** This is a Section 1 Item ******
In the performance of the above recommendation, we propose to use the
chemical Tim Bor (Disodium Octaborate Tetrahydrate) .
Item 1I: ADDITIONAL
RECOnM7ENDATION: After the shower repairs are completed we will reinstall the
same enclosure, silicone sealing all voids. If the same enclosure can not be
• reused a Supplemental Report will be issued outlining the cost to install a
new enclosure.
****** This is a Section 1 Item ******
THRASHER TERMITE & PEST CONTROL ---License No. PR 0240
THRASHER TERMITE & PEST *T`)L _ • Page 1 of 2
17427 Ntarley Road West
Los Gatos, CA 95030-3308
• Ph: (408) 354-9944 Fax: (408) 395-7934
WORK AUTHORIZATION CONTRACT
Address of Property: 10360 Phar Lap Drive, Cupertino, CA, 95014
Inspection Date: 06/11/2004
Reporthr: 26966
Title Co. & Escrow #: Cornerstone Title
Ad F
SECTION 1 SECTION 2 �' ®w -FIINFRMSPECTION
1 H: $ 4550. 00 1
11: $ 175.00 JUN 1•r L,V4
1J: $ 350.00
1 K: $ 320.00
CITY OF CUPERTINO
RUILDINr OFPAOTMENT
t
We Authorize the Following We Authorize the Following We Authorize the Following
Section 1 Items to he Performed. Section 2 Items to he Performed. Items for Further Inspection.
Proposed Cost Section 1: $ 5395.00 Proposed Cost Section 2: None Proposed Cost Fur.lnsp.: None
Inspection Fee: S Be #1E
Total: $ 5395.00
NOTICE TO PROPERTY OWNERS: (Section 7018 of the California Contractors License Law, Business & Professional Code Div. 3, Chap.
9.) Provides under the Mechanic's Lein Law any Structural Pest Control Operator who contracts to do work for you, any
contractor, subcontractor, laborer, supplier, or other person who helps to improve your property, but is not paid for his work
• or supplies has a right to enforce a claim against your property. This means that, after a court hearing, your property could
be sold by a contractor, in full, if the subcontractor, laborers, or suppliers remain unpaid.
BY EXECUTING THIS WORK AUTHORIZATION CONTRACT, CUSTOMER ACKNOWLEDGES THAT HE OR SHE HAS BEEN ADVISED OF THE FOREGOING AND HAS
HAD THE OPPORTUNITY TO CONSULT WITH A QUALIFIED PROFESSIONAL.
I have read this work authorization contract and WDO inpeetion report it refers to.
NED WORK AUTHORIZATION CONTRACT MUST BE RECEIVED BEFORE WORK WILL BE SCHEDULED.
ave read and understand the terms of this work authorization contract and hereby agree to all terms thereof. '
APPROVED AND READ BY: DATE ACCEPTED FOR: DATE
THRASHER TERMITE& PEST CONTROL
ar
kITY OF CUPERTINO* 6
CUPEIZTINO PERMIT APPLICATION FORM ' J
APN# 2 3 Date:
Building Addres Mailing Address (if different from building address):
Owner's Name: Phone#:
Me F rneG5 KLA r ll, .
o tractor: - #:
rt,Qrmk Pei - �K4& J FP- ozYD
Contact: Phone: Cupertino Business License#:
2fi rr�3�c_ Fax: YC*35y-99f'y 177&T
Building Permit Info:
Bld ,& Elect ❑ Plumb/'ff Mech ❑
Job Description:
Residential kb-R- S�Vor.✓-[L Commercial ❑
Sq.Ft. Floor Area:�b �g $/Sq.Ft.:
Cost of Project: ^ Occupancy Group:
SJTa• ,ro
Type of Construction: Please check this box if the project is a
ke ,A• second-story addition: ❑
Project Size: Standardg Large ❑ Major❑
Quantity Fee ID Fee Description Fee Group
BAPPLOTHER Other Appliances MECHANICAL
BBOILER1 Boiler<= 100,000 Btu MECHANICAL
BBOILER2 Boiler> 100K to 500K Btu MECHANICAL
BBOILER3 Boiler> 500K to 1M Btu MECHANICAL
BBOILER4 Boiler> 1M to 1.75 M Btu MECHANICAL
BBOILER5 Boiler> 1.75M Btu MECHANICAL
BCONSTAX Construction Tax BUILDING
BCONSTAX Ind/Off/Comm/Quasi BUILDING
BCONSTAXBQ Con. Tax for BQ Zone BUILDING
BCONSTAXH Hotel and Motel BUILDING
BCONSTAXR Constax—Resi/Mobile BUILDING
BELEC1000 Elec 600V <= 1000A ELECTRICAL
BELEC1001 Elec 600V> 1000A ELECTRICAL
BELEC200 Elec Svcs 600V<=200A ELECTRICAL
BENERGY . Energy BUILDING
BENERGYADD Energy Add Multi BUILDING
BINVESTIGA Investigation fee BUILDING
/ s-0 1 of 3
WITY OF CUPERTINOO
C Iwo CUPEkTINO
PERMIT APPLICATION FORM
Quantity- Fee ID Fee Description Fee Group
BMISCELL Miscellaneous Fee BUILDING
BMITIGATC Comm. Housing Mit. Fee BUILDING
BNUCOMME New Comm Electric ELECTRICAL
BNUCOMMM New Comm Mechanical MECHANICAL
BNUCOMMP New Comm Plumb PLUMBING
BOVERTME Inspection Overtime BUILDING
BPBACKFLOW Atmospheric Vacuum PLUMBING
BPCESSPOOL Cesspool PLUMBING
BPERMFEE Bldg Permit Fees BUILDING
BPFIXTURE Pblg Fixture PLUMBING
, BPGAS Gas Piping System Fee PLUMBING
BPINTERCEP Ind Waste Interceptor PLUMBING
BPLANCHK Plan Check Fee BUILDING
BPLANCKADD Plan Check Add Multi BUILDING
BPLANCKREP Plan Check Repeat Fee BUILDING
BPREPIPE Re i e Of Fixtures PLUMBING
BPSEWAGE Sewage Disposal PLUMBING
BPSEWER Sewers PLUMBING
BPSPRINK Lawn S rinklerBackflo PLUMBING
BPSTORM Storm/Rain Water PLUMBING
BPTRAP Kitchen Trap PLUMBING
BPVENT Alt of Drain &Vent PLUMBING
J BPWATER Install/Alter Water Pie PLUMBING
BPWHEATER Water HeaterNent PLUMBING
BPWSVCS Main Water Service PLUMBING
BREINSPECT Reinspection Fee BUILDING
BREMACOVER A/C Unit> 10,000 cfrn MECHANICAL
BREMAEUTAN A/C Units <= 10,000 cfm MECHANICAL
BREMAPPLI Appliance Install MECHANICAL
BREMBUSWAY Remodel Busways ELECTRICAL
BREMFIXT Lighting Fixtures ELECTRICAL
BREIv1FURN Relocation of Furnace MECHANICAL
BREMFURNOV Relo Fumace > l OK btu MECHANICAL
BREMHEAT Heater Installation MECHANICAL
BREMINHOOD Installation of Hood MECHANICAL
BREMMISC Misc Apparatus ELECTRICAL
BREMNRAPP Rem Non-Res Appliance ELECTRICAL
BREMPOLE Pole/Platform Fixture ELECTRICAL
BREMPOWER Power Device/Apparatus ELECTRICAL
BREMRECEPT Rc tl, Switch & Outlets ELECTRICAL
BREMRELOCA Relocation of Hood MECHANICAL
BREMREPALT Repair/Alter Heating MECHANICAL
BREMRESAPP I Remodel Res Appliance ELECTRICAL
2 of 3
OCITY OF tUPERTINC*
CUPEI�TINO PERMIT APPLICATION FORM
uanti Fee ID Fee Description Fee Group
BREMSIGNAD Rmdl Signs Add Branch ELECTRICAL
BREMSIGNS Remodel Signs, Marquee ELECTRICAL
BREMTHEATR Theatrical Lighting Fix ELECTRICAL
BREMVENFAN Vent Fan Single Duct MECHANICAL
BREMVENSYS Ventilation Systems MECHANICAL
BSCBLVD Scb Specific Plan .BUILDING
BSEISMICOM Seismic Commercial BUILDING
BSEISMICRE Seismic Fee Res BUILDING
BSPECIAL Special Insection BUILDING
BSWIM Swimming Pool BUILDING
BTEMP Temporary Power ELECTRICAL
BTEMPPERM Temporary Bldg Permit BUILDING.
BTEMPSVCS Temp Dist Svcs ELECTRICAL
BUSLIC Business License BUILDING ;
ELECTRIC Electrical sq foot ELECTRICAL
EPERMITFEE Elec Permit Issuance ELECTRICAL
MPERMFEE Mechanicals . foot MECHANICAL
MPERMITFEE Mech Permit Issuance MECHANICAL
PPERMITFEE Plumbing Permit Issue PLUMBING
PPLBG Plumbing Fee sq foot PLUMBING
ZADDCHG Address Chane BUILDING
k
3 of 3
i
1
CITY OF COPERTINO "� '= _ _ " ".- •*`' 91,
BUILDING DIVISION PERMIT Ct7NTRAC' 'bI2'.TNFyORMt1.TIU1 .
BUILDING ADDRESS: """""b4060108
ERMIT NO..4060108
OWNER'SNAME: PERMIT ISSUE DATE
JAMES KLAPPROT
E: SANITARY N0. CONTROL N0.
ARCHITECT/ENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
0 0 0 0
u o o LICENSED CONTRACT'OR'S DECLARATION
1 hereby off Bent 1 am IkenxO under provisions of Chapter 9(commencing Job DOSCfIpnOn
i ithSection] fDiviaio 7af the Byvinesx endP eslons Code,and mylicense is
=pa infullto can eat. AMS'."J r7ol-L( o REPAIR SHOWER (FUNGAS DAMAGE)
n r�2
Licenser) cornu
p Dake--cunlracwr CONTRACTOR: THRASHER TERMITE & PEST CONTROL $#17
7W ARCHITECTS DECLAR T
'ye n U 1 understand my plans shell be used u public records
Licensed Professimil
3 OWNER-BUILDER DECLARATION
aI 1 hereby AM.that I am exempt from the Contractor's License Law for the
i p o following reason.(Section 7031.5.Business and Professions Code:Any city or county
+�$ which requires a Permit to construct,altar,improve,demolish.or repair any structure
Prier m its issuance,also requires Ne applicant fonuch Permiuo ftle a signal sakmenl
�z
in.he is licensed pno...10the pmvisions of the Contractor's License Law(ChaPar 9 Sq.Ft. Floor Area Valua#(43550
$ (commencing wish Section 7")of Division 3 of the Business and Professions Code)ser
that he is exempt themfram and Ore band.for the alleged exemption.Any violation of
Section 7031.5 by any applicant for a permit subjects the applicant to a civil penally of APN Number OGCD
not more Nan five hundred doll..B500). Occupancy `7Pe
D L as owner of the property,or my employees wide wages as their role compensation, 32639032 . 00 araC
will do the work,and dee swctum isnot intended in offered for sale(Sec.7044,Business
and Profusions Code:The Contaclo'a Licenee Law docs not apply In an owner of Required Inspi tions
propenywho builds orimprovea dremon.andwho doessuch work himselforshrough his ��1� �
own employees.provided that such improvements are n(oinuended oroffered foraala If. tt n
however.the building or improvement is mid within one you ofcompletion,the owner. f(�
builder will have the burden of proving that he did not build or improve for purpose of
oak.). tl 7
❑1,as owner of Ne property,em exclusively contracting with licensed contractors in
construct the project(Sea 7044,Business and Protax ioos Cade:)The Contateme.Li. Y
cave taw due.ml apply to an owner of property who builds o improves Beeman,and
who contracts for such projects wish a com metar(s)licensed pursuant in Ne Continuities
Licenro Law. 1gY11
[_1 I sum exempt under Sec. ,B&P C for this mission
Owner Date
WORKER'S COMPENSATION DECLARATION
1 hereby affirm under penalty of perjury one of Ne following declarations:
harm and will maintain a Cenifrcata of Consent to self-insure for WorkeraCompen-
ton,an provided for by Section 3700 of the Labor Code,for the perfonnanw of she
work for which this permit is issued.
❑1 have and will maintain Worker's Compensation Insurance,as required by Section
3700 of the Labor Cade,for the performance,of Ne work for which this permit is issued.
My Worker's Cnmpy�en_satiagn-I-naunngf�e carder and Policy nun
Carrier +re d\ Policy: Q
CERTIFICATE OF EXEMPTION M RKEFR ERS'
COMPENSATION INSURANCE
(This section need mut becompletad Blue permll is Rican.hundred it.]].($1(I0)
or less.)
I certify Not in Ne Performance of dee work for which this permit In issued,l shall not
employ any person in any manner so as k become subject to the Workers'Compensation
Laws of California.Data
Applicant
NOTICE TO APPLICANT:If,after making this Certificate of Exemption,you should
become subject to the Worker's Compensation provision.of Ne LaNa Code,you most
.J O forthwith comply with such provisions or this Permit shall he decreed invoked.
Z" CONSTRUCTION LENDING AGENCY
ti
[r I barelywhich
Net there is a.d(So,.30 lending agency for the performance of
!Yi E Lwwmrk for which this permit is issued(Sec.3037,Civ.Cd
0.0 Lender's Name
]Z Lender's Address
C)Q I certify Nat 1 have read this application acrd slate that Ne above information is
ly F cored.T agree to comply wish all city and county ordinances and state laws relating to
Q V building convection,and hereby authorize representatives of this city to enter upon dee
W above-mentioned property for inspection purposes.
(We)agree to save,indemnify and keep harmless Ne City of Cupertino against
deet h
liabilities,judgments.costs and expenses which may in any way accrue against=it City /�•
V Z in consequence of the granting of this permit. /
"-' APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON. IN Issued by: Date I
S EGULATIONS. /
[ Re-roofs
Billion,,re,ofApplicaHAZARDOUS MATERIALS DISCL S ata Type of Roof
Will the applicant or future building occupantnmc or InI hsanctions materiel
as defined by tie,Cupertino Municipal Code.Chapter 9.11,and the Health and Safety
ode.ocean Sss31(e)? All roofs shall be inspected prior to any roofing material being installed.
Ycs *a
Will the applicant or future building occupant tau equipment or devices which If a roof is installed without first obtaining an inspection,I agree to remove
it haxardou.air conaminame av defined by the Bey Area Air Quality Management all new materials for inspection.
strict? J
Dyes pd Nu
(have mad Nc havNr/wsm\akrialsrcquimmenu under Chepkrb.95 o(Ne Caltfor- far
ria H.IN&Safety Code,Scctimu25505,25533 and 15534.1 undersand thmifd a building
does not currently have a tavnc shat it is my responsibility to not Ne,ocupens of Nc
reyuimmcntsw a bcm_etpporr�is_s7 ceofaCamfica f,,,gr.y. Signature of Applicant Dat
0 rurauthoriyedagcnl Date All roof coverings to be Class "B"or better