05060155 CITY OF CUPERTINO ;' X v ' �''•
BUILDING DIVISION PERMIT �C�ONTRAG OR2 INF ftMATTON•
BUILDING ADDRESS: PERMIT NO.0 5 0 6 015 5
Al C; PAT.VA rT
OWNER'S NAME: PERMIT ISUB DATE
I LIN 09/01/2005
E: SANITARY NO. CONTROL NO.
ARCHITECT/ENGINEER: BUILDING PERMIT INFO
9LDO ELECT PLUMB MECH
p
Y8 Zp LICENSED CONTRACTOR'S DECLARATION lois Description
I hemby afOrm Net 1 am licensed under provisions of Chapter 9(commencing P
< with Secdon 7")of Division 3 of the Business and Profcasions Code,and my license is
�< mmnfuoxtmdeffecl. ADD 514 ' LIVING/MASTERBEDRM/BATH/GARAGE 483 '
; Z Class
Dow. REMODEL KITCHEN/BEDROOMS
i Dem Contractor
E
ARCHITECrS DECLARATION WATER HEATER/PORCH
I understand my plain shell W used a public mind,
iC Licensed Professional
OWNER—BUILDER DECLARATION
I hereby affirm thin 11. .exempt from we r Cssions o Llecnu law for the
D en following reuoa(Section 7(131.5,Business and improve,
dem ns Cale:Any oily or county
$ which requires n permit re enres the alw,improve,h permit ore a sig any tatemum
prior m its hsuanCo,also requires the the applicant for Com permit m fde a tined statement
en which
he is licensed pursuantmthe provisions of Nc Contmcmt+Llecnse law(Chapter 9 Sq.Ft.Floor Area Valuation
(commencing with Section 7000)of Division 3 of dm Business and Profession Cade)at $140306
that he"exempt Ib ref ern and the buts for the alleged esmnpilm Any violation of
Section 7031.5 by my applicant for a permit subjects the applicant m a civil penally of APN Number Occupancy Type
rot mart than Eve hundred dollars(M),
❑I,u awmaf the proputy m my employm whh wgu u dmbmle oompewtion,
win do ft.,k.and the structure"oat intended«affered mr We(Sec.7044,Businm Required Inspections
and Profusions Cade:The ConuumY. u+^e Law dm net apply m an owner of q P
Property who bullds art improves them em,and who dose ouch work himself or through his
own employees.provided Nu such I m prmemenu art nm imended w o0cted for sale.It.
however,the building or Improvement It old within one year of oomple ion,the Owner.
builder will have Ne burden of proving that he did net Wild or improve for purpose of
I,u amen of the property,em uselusivcly convecting with licensed conbanmta m
tenet the project(Sec.1044,Business and Profossions Code:)TW Comssetme"Li-
cense law dm not apply to an owner of property who Wlma or improv Nemon.and
who Convects for such projects with a contractor(l)licensed pursuant to we Convecmis
License low.
❑nem ex5mpl-pnder Bea .Bk PCfar Ia renew
(C.X) / / —Done /_h/A /J
WORKER'SCOMPENSATION DECLARATION ,
I hereby afnrm under penalty of perjury ane of Ne following declarations:
❑I ham and will maintain a Cmificamof Consent m ul6buum for WarkcesCmpcn-
sation,u provided for by Section 3700 of the labor Code.for Ne pctformanoo of Ne
work for which this permit is issued.
❑1 haw and will maintain Woftes Compensation Insuranx,as required by Section
37W of we Ialmr Code.for the performance of the work for which this Peter,is issued.
My Worlds Campensadon lasumnce artier and Polity numb"art:
Courier. Palley No.:
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(rhisuction need not Wcompleoul if Ne permit Lot..hundm dollan(SIM)
or mos)
I Certify two In the perfoimenee of the..it for which this Psis is imsed,I shall not
employ a., mon In mymanner"u IpdferymGsubRcct io iM Workers'ComMnsadan
Laws of Califamia Do^ YY7711�� /a SJR,
Avpuesnt �) ��
NOTICE TO A L CA :If.allFir making this Cenificao of Exemption.you should
become subjectm the Worker's Compeuetion previsions of the Labor Cnua you must
,J O forthwith Comply with such provision or this permit shall be doomed revoked.zr~N., CONSTRUCTION LENDING AGENCY
F. 1 hereby afRrm Nat there la a construction lending agency for the performanec of
ai> the work for which this permit is Issued(Sec.3097,Civ.C.)
W Q landcr's Name
z Lender's Address
U 0 1 cmdfy that l have mad this application and tum that Ne me.information o
(L f" correct.l ague to comply with all city and county ordinances and sou Ism totaling m
DU building construction,and hereby suthodm rtpreunuuwf of this City to Cron upon Ne
W above-ownfoned pmpcny for inspection purposes
Ly,Lt, (We)agree to saw,indemnify and keep hanst we City of Cupenma against
t;y CM liabilities judgment",costs and expenses which may in my my moue against said Clry
U,'Z in consequence of the graining of this Permit.
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT Issued by:S44040H Date
SOURCE REGUr�IONS. Re-roofs
Signature ofnpplicmvcanl"nar Date 'Type of Roof
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant art future Wildiqg occupant pas whandle hazardous maori"
as defined by One Cupertino Municipal Code,Chapser 9.13.and Ne Nesbit and Safely
Code.Section 25531()7 All roofs shall be inspected prior to any roofing material being installed.
Y. XNu
Will the applicant or future building occupant Use equipment or deMm which If a roof is installed without first obtaining an inspection,I agree to remove
emit havardous air contaminants as defined by the Bay Area Air Quality Management all new materials for inspection.
Dist,ict7
❑Yea �No
I have mW the hazardous materials requirements underChap er6.95of Ne Califor.
nia HCul &S+fclyCodc,Sections 9505,25533 and 25531.1 umlcmtand that fthe building
does not c"acmiy have a tenant,0 1 it Is my responsibility m ratify Ne oecupanl of due
requirements usll)emct ormtoo ance.flccrtiBaamofoc y Signature of Applicant Date
l/ ' �u All roof coverings to be Class"B"or better
Owner or amhoriud.gem Dam