06090201 CITY OF CUPERTINO
BUILDING DIVISION PERMIT CONTRACTOR INFORMO,N 'n
BUILDING ADDRESS: PERMIT N0.06090201
7440 ROLLINGDELL DR
AlOWNER'S NAME: PERMIT ISSUE DATE
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SANITARY NO, CONTROL NO.
ARCHITECTYENGINEER: BUILDING PERMIT INFO
BLLK. ELECT PLUMB MECH
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aaCLICENSED CONTRACTOR'S DECLARATION Job Description 1 heroby".Nedal l am licensmdar Pmvvisioof chapur 9 soon,
u� with UCLion70M)or Division3afthe Business and Profcmiam Codc,aMmyliccn=is
no, Lfull
neClaatdarcat ADDITION 680 ' -FAMILY ROOM, KITCHEN, BAY WINDOW
iqz DOWmach:' Like. ALSO REROOF ENTIRE HOUSE.
o tare contDECL
As shall In An DECLARATION
i I underaund my plans shall be used AS public records
)yU
y Liomcd Pvfcssimnal
5
OWNER-BUILDER DECLARATION
ON
p I hereby.lien on I am aempt from Ne Contractor's License Law far the
O o following meson. oris t ]em art a..1w.Busines<andmpr improve,
dsioll Cod,:Any city or county
which requires a permit re rnnswet aper.improv,,demolish,nr repair any S.O.
prior At its issuer,also requires the applicant for such Atonia to tilt a signed summcm Qlb 7 7 1
-�< that W h licensed Purpmm m the pmvlsiom of the ConmaetRS lJccme law(Chapmr9 Sq.Ft.Floor Area Val$Qi
AFG (commencing with S¢sion]0Do)of Division 3 of the Businuset Prefessiov Code)or
Nat M is exempt IMmfrom and the basis for the alleged exemption.My violation of
Section 7031.5 by Ary applicant for a Permit suhjens No applicant to a civil penalty of APN Number Occupancy Type
not mom Nan five hundred dollar($500). 35931042 . 00
ne
will do Ne work-and the structure is not immmdcd of offered for sale(See.7044,Business
and Pv(csdons Code:The Coomctofs License Law does trot apply to in owner of Required Inspections
property who Wilds m improves tMenn.and whodoesswhoohhimrJfmt ugh his
Own employee,provided Nat such improvements art not intended proffered for We.If.
however,Ne building ar improvemat is Sold within one year of complefim,Ne mwnm-
builder .will ban the burden of proving Nat k did not hold or improve for purpose of
isle.).
1,As pone,of Na property,am exclusinly spanning with licensed cvnuamn m
c tract She project(Sec.7044,Business and Pmfesuam Code:)The Commctoes U
cave Lou does not apply to an mune,of p,mpcny who builds or improves thereon,and
who contracts fm such impacts with a cmnuacmKs)lic mend pursuam an the Contrxur's
Lkcnse law. _-
0 1 am exempt under Sec .B A P C fpr is mann
2
Owns
1 hereby AT.under penalty of perjury onto of the following declarations:
I h.ve.nd will maintain a Cenifea¢of Camera to self-imam for WorkelsCampen-
mian,as Provided fee by Sccuon 3](lo.f the labor Code,for the perfoenanne of the
we&for which this permit is issued.
0 1 have and will maintain Worker's CompensationInsurer.AS required by sued.
3700 of Ne labor Code,for the performance of Ne work for which this permit is issued. '
My Wprkcea Compensation homm nce canis and Policy number aro:
Cartier. Policy No.: _
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(Dissection need not he completed if the permit is Laron hundred dollars($100)
nr less.)
1 cent Nm in On Performance of the wart for which this permit is ismed,I shall not
employ anyperson in
Ccnifiatc of Exemption,you shold
became subject m the Woheri Compensation provisions of Ne labor Code,You mut
., z forthwith comply with such provisions or this permit she]he dcemed rewind.
ECONSTRUCTION LENDING AGENCY
[-� 1 h,reby afrum Out N,re is a covurecuon landing agency for ftperfmmamc of
Clft wish for which this Permit u issued(Sec.3097,Ci,C.)
Leader's Name
7 z Lemdm•s Address
U Q 1 cvmufy Nat 1 have rend this application and sum Nat tha about information u
U, F correct.I agree to comply with all city and county ordiummes and sum laws relating to
OV building construction.and hereby authorim representatives of Nb city to cnmr upnn On
above-menduned Pmpemy for inspection Portman,
F a (We)agree to save,indemnify And keep harmless Ne City of Cupertino agalmt
N Iiabilities.judgments.cmts andexpcvuwhich MAY in anywayseento agaiM=dCity
C)Z in comegtmme of the gnndng of this Permit Date .L '--G
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT Issued by: _�2
SOURCE
— Dam
HAZARDOUS MATERIALS DISCLOSURE Type of Roof
Will the applicant or(marc building occupanumm orhandlc handons material
As defined by f Cupertino Municipal Code.Chapmr 9.13.and On Haiti and Safety
Cutts.section 255324)7
❑Y VNa All roofs shall be inspected prior to any roofing material being installed.
Will the applicant or future building occupant use cquipmcnt or devices which If a roof is installed without first obtaining an inspection,I agree to remove
it havadov air contaminants A defined by On Bay Arca Air Quality Management all new materials for inspection.
Distoe,?
❑Yes gNp
I have read the havdtxs mm,riah mquimmcnu under Chapin,6.95 of Ne Califon
min Health h Safmy Codc,S,C6mns 25505,35533 and25534.1 undcrseed dun if the building
dos not currently hoc a¢nano ft it is my responsibility An notify dA"eupam of d¢
mquimmcnuwhkhmuA mnp6ormiuuarofaCenr=zofapArmy. Signature OfApplicant Date
amhomed ag,nL Dam g