05030023CITY OF CUPERTINO
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BUILDING DIVISION PERMIT
iTRAGTOR INF'ORMAgl`O
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BUILDING ADDRESS:
FIVE STAR WINDOWS
PERMITN.05030023
OWNER'S NAME:
PERMIT ISSUE DATE
ONE:
SANITARY OL NO.
HITEcTiENGMEER:
BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
LICENSED CONTRACIDWS DECLARATION
Jobb Description
1 bunchy affirm Nm External at I arna l under prevluon of chapter 9 (commencing
with Seedier 70 fDivis n3of Bm Business end Profeealon Code... my license
a
in full force and
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REPLACE WINDOW & DR. (ENTIRE HOUSE)
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Licensed Pmfevtional
OWNER -BUILDER DECLARATION
I Wo by afrom dui I am mempt Wm dm Conlracmfs License Law for the
following mon. (Section 70313. Business and limitations Cade: Any City or county
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which mqula permit to construct alma Improve, demolish. nr aper, any awmum
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poor h its luuanco, also mquims mu applicant fOrsmh permit te file a signed stsmment
thatW is llccnsed pursuant to the pmvialonnf the Conmmum's U.. Law (Chapter 9
Sq. Ft. Floor Area
Valu tion
(commencing with Section 7000) of Division 3 aide Burineuand Profession Cnae)w
that he is exempt therefrom and the buts for the alleged exemption. Any violation of
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Occupancy • Pe
Session 7031.5 by M applicant for a Permit subjects dm applicant m a civil penalty of
not moa Nan five hundred dollen ($500).
❑ 1, u owner of he property, O my employees wW wenad u duh sulc cempewtion,
Required Inspections
eis
will do the work, and dm smuctnte is not ln=d oreRered faraalefsec. 7044. Bualnas
and Profession, Code: The ConuecmLiam Law dead ant apply m an owner of
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property who W lldsor improves themen,and who doessuchworkli mself or through his
own employes, provided that such fmproremenu ate not Intended W Offered forsake. if.
however, the building or Improvement Is mid within one year of completion, the owner.
holder will have the burden of proving that he did Out build a Improve for purpose of
ale.).
❑ 1, as Owner of the Property, am ese ssively communing with Itanana conuanton to
construct the pmjen (Sec. 7044, Business and PmfcWon Cade:) The Coutoeter's Li-
cerse Law date not apply te an owner of pmpeny who Wilda or improve demon, and
who contracts for such projects with a eommctor(s) licensed punwm to the Cantnctefs
License law.
t] I sm exempt under Sec. . B At P C for this recon
Owner Dam
WORKER'S COMPENSATION DECLARATION
I hereby of neer under penalty of perjury one of he following declarations:
69 have and will maintain • c.mfiammrc.man nI te self -insure In, warkses Compen.
n, u pmvided for by'ne On 3700 of the IaWr Code, fn the performance of Be,
for hmh his permit I`ueuml
ave and will maintain W.kCe. Compenadon Insurance, as required by Section
3700 of he labor Code. for the perfmor men of he wort for which this permit is issued.
My Workices compeunlon loswance omier and Polity numLbeD
Carrier, iC]ifkNtQ 5 Polley No.: TI� T1 �q �
CERTIFICATE of EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(rob section need notwcomplemd time Permit Is foronc hundred doilan (SIM)
or leu.)
I certify that in the performance of he work for which his permit is issued, 1 shall not
employ any person In any manrcrse as m become subject to he WOYen' CompeuaBon
Laws of California. Date
Applicants
NOTICE TO APPLICANT: IL after making this Cenifiam of Exemption, you should
become subject se the Worker's Compensation provision of he labor Code. you mum
foMwith comply with such provisions or his permit shall W decmpd revoked.
CONSTRUCTION LENDING AGENCY
I hemby affirm that them is a construction lending agency for the performance of
he work for which this permit is issued (Sec. 3097, Civ. C.)
Lender's Name
Leonine. Address
above Information so
I certify that 1 have read this city
coned I ansa te comply with all city and county ordinances and sum law.
an coup sena atsm Nat and
r upon t e
Wove- construction, any therebyins euhon p representatives tsdvu of hb city te enter upon me
shove- (We) ed propene for inspection purposes.
(We) agree in ave, indemnify and keep hatmlrss the City of Cupertino against
liabilities. judgments. cam and cape which may in any way amen galnaaid City
nI onranee of the punting of th pe II.
APPL NDE AND N ILL COMPLY WITH ALL NON -POI
Issued by: Date �l
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Re -roofs
sign tea lion de n Data
HAZA US MATERIALS DISCLOSURE
Type of Roof
Wil heap 'eemor fuhm Wilding occupant mom or handle hazardous material
as definedBm C nine Municipal Cade, Chapmr 9.13, and he Health and Safety
code. recd%25(.)?
All roofs shall be inspected prior to any roofing material being installed.
❑Yat you
If a roof,iS installed without first obtaining an inspection, I agree to remove
Will On applicant or future wading Occupant ate equipment or Oovice, which
It heurdnus air contaminants as defined by me Bay Area Air Quality Management
all new materials for inspection.
Oct?
❑ Yea Wr_
I have mail he huaranusmamdab y iromenu under Chapter Q95afhe Califte.
niaxal tit SarciyCodc, 'ou Z55f15. s and 73534.IundcnuM thulfhe wilding
son no nen . nL sponibility te notify dm 112 of he
to net rr ceofaCersiOcamarampancy.
SignatureofApplicant Date
All roof coverings to be Class "B" or better
owns a ,m n spam t I Dam
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