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05030165 CITY OF CUPERTINO Y� �'fi r^�,.�.c v�' �w'o e""'�'�',lvb' 'y7 'n/�� °i°r"''S' BUILDING DIVISION PERMIT do - IL 4Tl1R�INl ORS AIVNt d. � . BUILDING ADDRESS: PERMIAN BUILDERS INC. PERMIT NO.05030165 OWNER'S NAME: PERMIT ISSUE DATE E: SANITARY O OL NO. ARCHITEC rENGINEER: BUILDING PERMIT INFO BLDO ELECT PLUMB MECH pC = C= E= Ypp LICENSED CONTRACTOR'S DECLARATION Job Description I hereby affirm that 1 am licensed under provisions of Chapter 9 momma with Section TON)of Division 3 of the Bond.end Professions Code,a e in full fortt an cff NZ LlankLT B Lm.l NTERIOR TI-ADD OCFFIAC�ES/BREAKRM ` Deck used r F I,VALE® exp+ ARCHITECTS DECLARATION C ©C 9 yKp I undeuund my plans shall he used u public keorN 1,b Licensed Profcasionsl OWNER-BUILDER DECLARATION -5-/ + ^ 0 I hereby.(firm that 11. exempt from the Tessio Co License Lew for IM V M 2005 ipo whichingrearon.(SecOun.anstr,Buslan, end .. eimis Code:Any city or county $ which its issuance, n permB recMatme etre,,improve,demnlW,ri repatr any tataluk FZSn potmn.licensedp.orequlma tMvision Of fonah PermrO.fdeuLw(atammant Fp< mnnaieEanseapat,aa^tklh<pmaiaonsnfukcomt><knl.hen:<Lwfch.pin9 Sq.Ft.Floor Ar ANG-Valuation HE (commencing with Scnion7000)of Division 3 ofthe Business and ProfessionsCate)or 6`l Net he B exempt Horsham and Ne bash for Ne alleged exemption.Any violation of S^cdon,7031.5 by any applicant for a Permit objects the applicant to a civil penalty of APN Number Occupancy Type not mac than ave hundred della,,($500). ❑1,an owner.(the property,or my employees with wales As dkbwle compensation, will do the work,and the structure is notimended mortared result(See.7011.Business 1606033 . 00 and Professions Cade:The Contractor's License law does ant apply W an mane,of Required Inspections property who builds or Improved thereon,andwhodoesouchsoakhimselfor though his .wnemplayeea,provided that inch Improvemenuue not intended a.Rereal for Ale.IL however,the building or improvement is sold within one yaw of eompledon,the nwner- builder will hour the burden of proving that he did not build or Improve for purpose of W.J. ❑1,as owner of the property,am exclusively connecting with licensed contractors to construct the project(Sec.WN,Business and PTofmsimes Code:)The Conueckr's Li- cense Law does not apply W an owmr of property who builds per improves themM,and, who contracts fa such projects with a comneWr(O licensed pursuant to the Canl,,maYe Lkense Law. ❑1 am exempt under See. .B l:P C fm this reason Owner Dab WORKER'S COMPENSATION DECLARATION lb I hereby affirm under penalty of perjury one of the following declarations: 1 Mm and will maintain a Certificate of Coment to self-Insure for WorkeM1Compen. nation.u provided for by Section 37M of the labor Code,for the performa=of the work for which this pmmlt Is Wood. ❑1 have and will maintain Worker's Compensation Women,As mquired by Section 37M of me labor Code.for the prformaocc or the work for which this permit 1.Wood. t My Worker nmpenss Ion Insurance canis And Policy number am' s C.Mer:, �(�(�L Policy No.:_k!�"_ �v CERTIFICATE OF EXEMPTION FROM WORKERS' COMPENSATION INSURANCE (This section need not b.eampleted if the Permit is faonchu^dmddollen(SIM) a leu.) I comfy that In the performance of the work fa which this Permit Is Issued,I shall not employ any person In any manner an As W become subject to d¢Workers'C=PeMRlmn Law of California.Dam Applicant NOTICE TO APPLICANT:If,after meting this Certificate of Exemption,you should become subject W the Worker's Compensation provisions Of the Labor Code,you..or - .J O forthwith comply with such provisions or ails permll chill be domed revoked. 7 y CONSTRUCTION LENDINO AGENCY [ti 1hereby.fram that mem isac^nsuuction lmlaint atency fm the perfamameof the work for which this permit is issued(Sec.3097.Ci,C.) W Q Lendcea Nunc Lot, re Addre.s O Q I ttnify met I hive ked Ihls application end sum that the.bow information is (L F coned.l agrce to comply with all city and county omimmes and since laws relating 10 Q V building construction.and hereby arch^rlk representatives or suis city to enter upon the W above-memoned property for inspection purposes P. (We)agree I.Ave,Indemnify ani keep hum the City of Cupertino gams, IA llabllities,Judgments.comande nsnsw airy ywy.mue apinn tend city C.1 7 In consequence of the ton let F7 APPLICANT UNDERST P WITH ALL NON-P01 Issued by:9 Date SOURCE REGULATIO Re-roofs Sllanme.f Applic. o r or Dam AZARD 5 TERIALS DISCLOSURE Type of Roof Wlllmeappri or future lding.aupanistaearhandlchaamuusmsksisi a defined by dm Cupenin.Muni MI Code,Chapter 9.13,and the Health and Safety Cam.Section 25537(.)7 All roofs shall he inspected prior to any roofing material being installed. ❑Yes X. Will the applicant or future building occupant no equipment at devices which If a roof is installed without first obtaining an inspection,I agree to remove B haardons air contaminants a dented by the nay Area Air Quality Management all new materials for inspection. District? ❑Yea n I have mad awry en curl qulmmts under chapter 6.95 of the Califor. nla Heald&S 5 I 25 5533 Anal 25534.1 makmauM most if he Wilding does not can rupoulhiliiy W Mary the occupant of me requlrtm at miss ..r.ccNBcamofO n an� Signature of Applicant Date Ownr ancon Dam All roof coverings to be Class"B"or better