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CITY OF CUPERTINO
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BUILDING DIVISION PET
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BUILDING ADDRESS:
PERMIT N105070116
' R'S NAME:
PERMIT ISSUE DATE
DAN COOK AND KELLY DAO
117119/2,M)C;
PHONE:
SANITARY NO. CONTROL NO.
ARCHMECTIENGINEER:
BUILDING PERMIT INFO
BLDGO PLUMB MECH
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LICENSED CONTRACTOR'S DECLARATION
Job Description
1 he10by els. Net l am IIcemW under provisions n(Chapnr Y (commcncing
with Smdon 7011(1) of Division Jof We Buri. W ProfeWoas Code. and mY Ii. u
Wtall force and ea
KITCHEN/BATH NON STRUCTURAL MASTER BATH 2ND FL
icen
LCI Lk. Y
Dote cdnDECL
LAUNDRY ROOM 2 BATH
ARCHITECTS DECLA ATION
e
,/) shall he used u public records
ypng9rpm9J Win"
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OWNER -BUILDER
m tic CmuION
1 hereby .(Seco thato for the
1a.1. exempt from tic Caii.. Co License city
]1131A, Business and y ar county
claudi Code: Anyrepair
KJ 2005
whichfollow
dyes a Permit t ve, m sig any aometme
which requires a Permit re cortsbuct W prow, do
ornit t e a
prior to its issuance, Shu requires the applicant fonuch permiuo Ole a signal emkmcnl
applicant tement
Out he is licensed pursuant to We provi tom, of We Contra mos License Law (Chapter 9
Sq. Ft. Floor Valu0i90000
(commencing with Seniors 7000) of Division J of Ne Busineasand Professiav CoM) car
INa
Oat hein exempt therefrom and We bash for On alleged exemption. My violation of
Section 7031.3 by any applicants for a permit objects the applicant to a civil penally of
APN Number Occupancy 7
P y ' T
not mom than an hundred dollars ($300).
36934019.00
❑Les owmr of theproperty, or my employees with warm as thebmle compenaadon,
Required Inspections
will do the work, and the modaut, is not Intended oroRered for ase (Sec.7044, Business
And Pref emms Code: The Comnnofs License Law does not apply W an owner of
property who buildear Improv Warms, andwho doesauch work himself or Wnugh his
own cmplayess, provided thatsuch impro mumassre notimended armament forsake. if.
however, the building or Improvement Is cold within ore )ear of compkdan, Warrantor.
builder will ban We buNm of proving that he did not Wild or Improve for purpose of
aale.).
0 1, as owner of the property, am exclusively contracting with licensed convectors to
.
construct the project (Sea 7044. Business and Profession Code:) The Cantncuu's U.
cease Law does not apply to an owner or property who Wilds or improro thereon. and
who contracts for such projects with a conlnctor(s) licensed pursuant to We Commences
L a nse law.
❑ I am exempt under Sec .BAPCfmthumaaon
r Dam
WORKER'S COMPENSATION DECLARATION
I hereby efMn under penury of perjury am of Ute follewing declarations:
❑1hartonewillmaintaina CeniOcaseof Contenttoself-imumrte Wor e$Compcn-
cation, u provided for by Section 37M of the Labor Code. for the performance of the
work for which Nis permit is Issued.
0 1 haw and will maintain Warker's Compensation Incomes. as required! by Section
3700 of the Labor Code, for the performance of the woh for which this permit Is send.
My Workces Compensation Insurance cancer and Policy number are: p
Cartier:' 41 fie 14,/ d PolicyNo.: 60421 <"
CERTIFICATE OF EXEMPTION FROM WORKERS*
COMPENSATION INSURANCE
(Tboacalon need sol becompleted If the permit Isforonc hundred dollen ($11)(1)
or Met)
I carry met in We performance or the work for which this permit is issued, I shall not
employ any person In my democrm As to became subject in the Workne• Compensation
Laws of C.Iifomla. Dam
Applicant
NOTICE TO APPLICANT. If, after meting this CertlResto of Ewm(dton, you should
become subject W We Workers Compensation provisions of Wa Labor Codc, you moa
forthwith comply with such provisions or this permit shall W deemed masked.
CONSTRUCTION LENDING AGENCY
I hereby arm that Were is a coasttuctinn lending agency for the performence of
We work for which this permit Is issued (Sm. 3097, Co. C.)
Lender's Name
,
Lender's Addmas
I certify that 1 have maid this application and state that the show information is
'
cormm I agree to comply with ail city and county omilwtces and mm lawn relating W
building construction, and hereby authaWm mpmomasti s of this city to enter open the
_
save-mentional property for inspection purposes
(We) agree to caw, indemnify and kmp harmless the City or Cupertino against
Ilabilit es,jolments. costs and expenses which may In my way same against said City
s rmit.
APPLICANT UNDERSTANDS Aterliof IND WILL COMPLY WITH ALL NON -POINT
Issued by: Date
SOU E A ONS.
ONS.
Re -roofs
Type of Roof
Sigmmrt ar ApplicanaCa ter - Date
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future building mcupant 11010 mhanmc hmudous as urlai
as defir ed by We Casper.. Municipal Code. Chapmr 9.11. and the Health and Safety
Section 23532(k)]
ElYes 0
All roofs shall be inspected prior to any roofing material being installed.
If a roof is installed without first obtaining an inspection, I agree to remove
Will the applicant or future building occupant use equipment or dcvMco which
emit haradnn air conumimnu as defined by do Bay Arca Air Quality Management
all new materials for inspection.
District?
❑Yea
' I have tend the hxrammsmawriahmquimmcnB undcrChapter03 ofthc Califor.
ata Hal&SsetyCode, Sections 23305, 25533mul 25534. l underaund thuifde Wilding
does not g4en1 1 ant, that II h my responsibility W nodfy We occupant of the
resrcm o w I h et , �umrcar Gentile to r n/pan=.
q I�j ��
Signature of Applicant Date
All roof coverings to be Class "B" or better
owner 1
r authonm ascan gn