08040091 CITY OF.CUPERTINO .P t��t ",=„J:• h x^' '- -"- r�:•'
BUILDING DIVISION PERNUT zCONTR:�CTORI ko TrdN„ _
BUIL 1 GA RESS: PERMIT NO.
4'9�. PINEVILLE AVE DWK CONSTRUCTION 08040091
NER'S NAME: PERMIT ISSUE DATE
UnV1:1) LU 18665 LOREE AVE 07/31/2008
PHONE: SANITARY NO, CONTROL NO.
(408) _ __ _R
ARCHITEC(ENGINEER: ?y — �/� BUILDING PERMIT INFO
f BLDG ELECT PLUMB MECH
0 0 0 0
30; LICENSED CONTRACTOR'S DECLARATION Job Description
ap 1 hucby allinn mad I am licensed under provisions of Chapter 9(comntenIct, p
wish,
ith Sm6.70M)of Division 3 of am Burnes and Profevrimun Code,and my He..0 ADD490SQ LV SPC,MSTRSTE&FAMRM RPLC EXSTNG FIREPLC
n<i in full forte and effect I !]�OZ/
>'q_ Lt..so Cass Lm.« n W/ GASFIREPLC
r Dam Comramr
PNKftads tea!)
ARCHr1EC7rS DECLARATION
I undemanJ my Plans shall be used as public mcnrds
g a,t; Licensed Professional
a v,3 OWNER-BUILDER DECLARATION
i I hereby aRrm that 1 am exempt from the Contractors License Law for the
COC following reason.(Section 1031.5,Business and Profeviov Codc:Any city or county
$ which requires a permit to construct.alcor.improve.demolish,or repJr any siructma '
prior m its issuance,also requiees she applicant for such Permit m fico.signed satemmr
s< wpm
t he is licensed around to Ne provisions ofNva
c Concara License Law(Clmapta9 Sq.Ft. Floor Area Valuation
yF 0 (commencing with Section 7MlBof Division 3orOn,Business and Profeadmu;Codc)or $50000
Q
Out M u cumm in tharefrcand the basis for the alleged caempcon.Any violation of
Section 7031.5 by arty appBam turn permit subjecu thc applicant to act ponally of Number Occupancy Type
hat more dont Irv,hundred dollars($500). 36913021 .'lYU'
Luownm of cone pe mbroun mmyemploycrs wlNwagvarthdvsole W.Beat an,
and de thcweek,atm the shmnae u netinmnded mea w de foraalo(ply to an Bvi^•of
dna Prey wW ns Cmc:The Cat dacmrs had
Law dens con apply lf an ewmr of Required Inspections
aw.tan who buildssi edprovesch improvements m and who doesaucn work Aorticof ad Nrougs hu
own,ar,meea,ping or i pr such tUsold Mil arcml ear of forum.lf.
harder,,Ne ava One
un improvement is sola within arc year of wmple far the harder will wi0 luso Ne burdan of peeving Nat k did not dub m improve fm purpose of
u6.1.
❑1,as owner of Ne properly,am exclusively contracting with licensed contactors lo
consumes Ne project(Sec.70",Business am Professions Cede:)The Cmvacmrs U. .
cove law does not apply m an owner of property who dtlN or improves Merton,and
who conuacu for such ponjeeu with a eonuacar(s)licensed pursuant to the Canvasses
License Law.
❑I am eaempt under See ,B At PC fns this wan
Pro,
Data
WORKER'S COMPENSATION DECLARATION
1 bembY affirm under penalty of perjury one of the following dmlarntme,
I ham and will malnWns Ce icor ofCoventtovlf-Wumfm Workers Compete
ration,an provided for by Section 37W of Ne Labor Code,for the performance of the
work for which Nu permit is issued.
0 1 have and will maim em Workers Compensation Insurance,as received by Section
3700 or Ne Labor Code.feu Ne performance of Ne work for which this permit is issued. '
My Workers Campewton assurance artier and Policy number are:
Carrier: Policy No.:
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
fThusection m<d mtbccompimed If to permit is for oro hundred daBus(SIM)
or less)
I certfv thus in the pm(mmance of the work for which Nis permit is issmd.I shall not
employ any parson in any re!4 p unorre subject s the WorkesY CompensationLaws of California Das r O
Applicant
NOTICE TO APPLICANT:If,after making this Certificate of Exemption,you should
become subject in the Worker's Compensation provisions of the Labor Cmc,you most
.J O forthwith comply with such purviuens m Nu Permit zon be deemed remtrl
z CONSTRUCTION LENDING AGENCY
F.h (her which tithuthem Wood
mndingagcncy fm is pesurmame u(
Ci> Ne gess red which this permit V issues(Sec.309],Civ.C.)
�W 0 Lenders Name
� z lnnaersndaw
V o 1 comfy that I bays read des applicator and sum an the above information in
It, corncL I sp ns m comply with JI CRY and cowry ordinances and sum laws relating lo
.C) Wilding construction.and hereby authosise representatives of this city to enter upon the
aneve-mcodo nd propeny for inspection purposes.
F 6Wi (We)agree m save,indemnify and keep harmless the City of Cupertino agmen
H liabilities
U imgmenu,costs and apenu+which may any way magalvnsald City
Z incnescopNcStAPPLCTUNDEof On,RTANDS AND
WILL COMPLY WITH ALL NON-POINT Issued by: Date
SOURCE REGULATIONS.
��� ��l/ 7 o-6t 2/-0 shenor ppfianUConuacmr �� Re-roofs
HAZARDOUS MATERIALS DISCLOSURE Type of Roof
Will Ne appliant or future Wilding mcupanlaom or handle haamons ma and
as denxa by the Cupertino Municipal Code,Chapter 9.12,and the Health and Safcty
.Section 2553247
pyo . XNa All roofs shall be inspected prior to any roofing material being installed.
Will doe applicmt or to=building occupant use armmount m devices which If a roof is installed without first obtaining an inspection,I agree to remove
emir haasmov it conmmimmt as def,.d by On,Bay Area Air Quality Management all new materials for inspection.
District?
t]Ya No
1 have mal the hvamuu mamnalssquimmenu under CTumer6.95ofthc Cxlifor.
nix Hcal"Safety Cede.Sections 25505,25533 and25534.1 understand thaifdm Wilding
duan not currently bene a unam,out in is my responsibility be mtfy,One=upset of ter
require^ Is lush,mmbemetpiorairsmanceoracemrcacorfxcupahcy. Signature of Applicant Date
G� ��p� _3/ All roof coverings to be Classor better
Owner or authosiud agent V
� — pate'