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CITY OF CUPERTINO
CONTT2AC1'pRflIN'F`(.y2MATION"g
BUILDING DIVISION PERMIT
BUILDINGADDRESS:
1071q PTTqnT.R 17T
R L BRACKETT CONSTRUCTION
tiilaLrNO-05080081
OWNER'S NAME:
PERMIT ISSUE DATE
DAN CO
5
E:
SANITARY NO. CONTROL NO.
(408)235-8852
ARCH17ECTIENGINEER:
BUILDING PERMIT INFO
BLDGEIF.CP PLUMB MECH
t� I E t�
LICENSED CONTRACTOR'S DECLARATION
-
Job Description
1 hemby of ire that 1 un licensed under provisions of Chapter 9 (commm¢ing
with Section 7") a(Dlvlalan 3 of the Business anda my he.0
in full forte and affect
REVISION --BEAM SUPPORT FAM. RM/FL. JOIST
Licence les Lic.N
BEAM STAIRS/NO NEW PERMIT ISSUED/
ORIG. #05070116
mm Conlmr
ra
CHITERS DECLARATION
I undcnund my oleos mail Wused upublic records
Licensed ftmunionml
OWNER -BUILDER DECLARATION
1 hemhy affirm that I am exempt from Ne Contractors License Law for the
following won. (Section 7031$ Business and Professions Code: Any City or county
which requires a permit LL) construct. alter, improve. demolish. or sepalur my structure
prior m its issuance, also requires the spplicat for such permit to file a signed statement
that he is licensed pustamt to the provisions of the Conlrauri Lt.. Law (Chapter 9
Sq. Ft. Floor Area
Valuation
(commencing with Section 70D0) of Division 3 or the Business and Professions Cade) or
Q Q
Wt he Is exempt therefrom and the anis for the alleged camption. Any violation of
Y
APN Number
Occupancy ATL,
pane y `'
Section 7031.5 by my applicants par. permit ubjects the applicant he dAI penally of
not mom than five handed dollars ($500).
❑ I, as owner or Ne property, or my employees WIN wages as Neirsom compenudon,
Required Inspections
willdo thework, and Ne,wmue b notineMN wartemd far Ne (Sm.70a. Businra
and Professions Cox: The Contractors License law does ent apply m an awnr or
propenywho builds or mprons dereon.and whodmssuch work himsetforthrough his
own employee,, provided that such impmvemenu tie not Intended or opened for sale B,
however, the building or improvement is sold within one year of compichm. Ne owner.
builder will Mve the burden of proving Nn he did not build or improve for purpose of
sate)
Professing with :) TheCanlnoass I.
❑ I. u avecp of the property, am onus and
construct the (See. 70", Barer and Profession Cade:) The Contractors
es not who rad
ave taw doss not apply m an owner or property who Wild, or improves Neuron, ores ,
of property
whoafor pmJkets with aeanac
trtlicenseda)licensPursuContContractorsd puunt the Contractors
License LM
❑ 1 am exempt undo See. . B At P C (or this ..on
V
ff
Owner Date
�Q
WORKER'S COMPENSATION DECLARATION
1 hereby aftirm under penally of perjury me of the following decimations:
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1 as. and will retinlale a Certificate of Common an calf -insure for WwkCra C.P..-
.Pemnation,
nation,as provided far by Section 3700 of the Labor Code, for Ne padormaa radio
Work for which this Permit is issued.
❑ 1 M. and will m name, Workers Compensation Insurance, as required by Section
37M of The Later Code. for the performance of the work for which this permit is issued.
My Workers Compensation Maraca artier and Polity
Carrier. S4f4+P(14� at Polity Ni
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
CTbb seedon head notlecwnpleted irthe permb is forest: hundred dollars (5100)
or last
I anify the In de Perfomarm of de work for which Nin Permit is issucQ I shall not
employ any person in any mannerm as to become subject to the Workui Compenudon
Laws of Cdifen ice. Date
Applicant
NOTICE TO APPLICANT: Jr. after making this Cmilmae of Exemption, you should
become subject to the Worker's Compensation provisions of Na labor Cox, you mall
foMwith comply with such provision or this permit mall Is, deemed evoked.
CONSTRUCTION LENDING AGENCY
I hereby affirm wt thea Is a eonarwdnn lending sit for de perrnmana of
the Work for which this permit 1, named (see. 31»7. Civ, C.)
Landers Name
,
Lenders Add.
I eemfy Nat I have mad this application and mum Nat the above inrmmatins b
eo rect. l agme to comply with all city and county ordinances and sum laws elating to
building construction. and hereby authodm mprosenutivos of this city he enter upon the
above-mentimand property for inspection Purposes
(We) agree to save, indemnify ad keep hamles, the City of Cupertino against
liabilities. judgments. costs and expenses which may In any way new pains, aid City
in consequence of she gnnling of this IX.iL
APPLICNDE STANDS AND WILL COMPLY WITH ALL NON -POINT
Issued by: Date
SOURC
ki 311 oS
Re -roofs
Signature of AppliaR mor Data
HAZARDOUS
HAZARDOUS MATERIALS DISCLOSURE
Type of Roof
Will a l or future Waat nam araMk wardnw roamed
in denaa by the Cupertino Municipal Coe. Ch,pmr 9.12. and the xaw as sassy
Cox. Section 25532(a)7N
All roofs shall be inspected prior to any roofing material being installed.
[I Y. o
If a roof is installed without first obtaining an inspection, I agree to remove
Will the applicant or future Wilding occupant use equipment or devices which
I Mumbles air conlalninnta u depend by the Bay ACs Air Quality Management
all new materials for inspection.
Dimict7
❑Ya Y[!u
I ave mud the huardnumatefbbrequircmme; underCapter6.95of the Califs.
all HalN&SafelyCade, Sectiwd 25505.25533 md25534. 1 understand thBifthe Wilding
n e
does cu dy mnsnL that it is my responsibility ibility nodl'y she mcupat of Ne
req rat ,hi t darnlwuue arae Nkayf(JC3u(icos
I/ (Dow
Signature of Applicant Date
YJ
All roof coverings to be Class "B" or better
Owner
or authadmil agent