05010175 ITY OF CUPERTINO �•v1�]r�.aee».• aF', y �'y
BUILDING DIVISION PERMIT ''''OMIT '..Q gNFO�AT �L�1
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u1DINOADDREss: PETER LETCHWORTH PERMIT N%5010175
ER'S NAME: PERMIT ISSUE DATE
PETER TsF.TCRWORT14
ONE: SANITARY NO. CONTROL NO.
ARCHITECT/ENGINEER: BUILDING PERMIT INFO
BIRO EIF.CT PLUMB MECH
�06 LICENSED CONTRACTOR'S DECLARATION O O
1 hereby a(rlmt that I am Ikcneetl under provitlmu of Chapter 9(commencing Job De
wish llto=7Op)ocDivWon3of the Business and Profculam Code.sotlmylicense 4 B'�
mrmuo.and ertea As
6 ' DOOR OPENING IN NON-
y z ucen¢Class Lie.
L Dam canlranar
ARCHITECTS DECLARATION ��� ^ti L vl
as00c
3 (
I understand my plan shall W used u public records
A. Licensed Prefesaiaml
y OWNER-BUILDER DECLARATION 8 p ®� Admix
I hereby a0bm Net 11. exempt from lite CantrunCo :Any c law for the N®L 161
0 o following mason.(Sateen 703 1.5,Business and Profession Cale:Any city or county
$ which requtres•permit m enmuuct,else,improve,denu lbh,or repair any sWnum
FZ� term An its issuance.also requires the applicant f.such permit he rile a signed comment
gg <
that Wislicensed pu ems,WoeprovisionsofsheCommetetsLicerme Law(Chapter 9 Sq. Ft. Floor Area Valuation
$ (comm wing with Section 7000)of Division 3 ofthe Boalwasantl ProfeulonsCMe)or
dust W u exempt therefrom
end the Was for Lha alleged exemption My violation of
Section 7031.3 by any applicant for a permit objects the applicant to a civil penalty of 3 5 'Qlidfinee0 0 Occupancy nm mom than Rve hundred dollars(M). P y Ty'Pe
❑I,as owner of the property.a my employees with wages u their sore compenudon,
will do the work,and tha structure is not Intended aaff and for ule(See.7044,Business
and Pro(eadons Code:The Connotes License law don Out apply in an awner of Required Inspections
property,who builds At impureness theorem,and who does such work himself or through his
awn employees.provided that such improvemem art not InmMed aoOeradforula If.
however.the Wilding or improvement is sold within We 3w of eemplamo.the Moves.
Wilder will have W Arden of proving that W did tet Wild or improve for purpose of
ale.).
❑1,An owner of the property,am mchnively contracting with licensed cormoters he
consumer to pmjen(Sec.7044.Business and Pro(esaiom Code:)The Con actoes U.
ams law dean not apply he an owner a(prnpmy who Wilds or Improves Norton.and,
who contracts for such projects with aeomrumr(O licensed pursuant M dmcennutofs
License law.
1 am exempt under Sec.I .B t P C for this moon
Dam VZIT O-S-
WORKERS COMPENSATION DECLARATION
I hemby cram,under pemlty of peryvy aro of the following declarations:
I have and will maintain a CertlOcate acomem to self-nsum for Watmes Compen-
Wian,u provided for by Satan 3700 of to labor Code.for the perfotmane,of Ilse:
work for which this permit Is issued.
❑1 love and will maintain Wuke(s Comperusumn Insurance,u required by Section
31W of the labor CWC,for the per(ormame Allies work for which this permit u issued.
My Worker'.Compmeram.Imuran.Cartier and Policy number tee:
Cartier: Policy No.:
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(fhb section wed nothacompletcd if the permit Isforow hutdmdtlollan(SIM)
.less.)
1 certify Not in the performance of she work for which this permit H Issued,l$hall nut
employ any person In any Manor 0 As m become subject a the Worker'Compees w
Law of CAHIMM,Dam
Applicant
NOTICE TO APPLICANT:If.after Makin{this CcNOcate of Exemption,you should
bosoms subject M the Worker's Compensation provisions of the labor Code,you mute
O forthwith comply with such Possums or this permit shall W dwmed revoked.
.7 y CONSTRUCTION LENDING AGENCY
(r Ihereby an.that them Is a construction lendingagewy for the performance of
C> the work fa which this permit is issued(Sec.3097,Civ.c.)
WQ Lenders Name
�
n7. Z Lender's Addma$ /•
U Q I certify ctio T have meal this applicn pr and rete that the above information e - (�
U, coma 1 a{ma a comply with all city and county ordlnswes and mute law$totaling to
abon-sg construction.and forherebyIMPuthadxe rprrxnuuwa of this city a cater upon lW
W above(We)
property for imiupecton keep a
4 (Wc)agta b nm,indemnify and lap humkss the City o(Cupertino against
ver N Ilabilitiu,judgments.cwu ad expenses which main any way accrue gaiMuid City �f /
L)7 Inrn
coerstone,of the granting 0(this Permit. d—�/jf ^O
G APPLICANT of
AND WILL COMPLY WITH ALL NON-POINT Issued by: Date
sa�TCB REGULATION$. n n cn r„ / /S
�/su�z� Ayprr t I z S e Re-roofs
Si{nuum of AppliuHAZA HAZARDOUS
Dam
HAZARDOUS MATERIALS DISCLOSURE Type of Roof
WIII dm applicant or(mum Wilding at 9se.auntie hsuNom material
defined by 1W Cupertino Municipal Code.e.Chapter
9.13,coil de Health and Safety
Cl Yes e,Socte35s3z(a)i 1!(N. All roofs shall be inspected prior to any roofing material being installed.
Will the applicant or future Wilding Occupant use equlpmut m deviau which If a roof is installed without first obtaining an inspection,I agree to remove
emit huardnm air coruminanu As dented by the Bay Area Air Quality Management '
DIAIcG all new materials for inspection.
❑Yoe 0 fptr •�
I have mad the harard,ms materialsmquiremcnu under Chapter 6.95ofthe Glifm•
nu$WIthaSalcty Cam.Swdm25505.25533wal75534.11mdcn ftifde building
does not currently hate a tenant,that it is my responsibility M only the occupant of she
M4.1 umgichmu x et relara99���ar.Gmrtamyraen ry Signature of Applicant Date
req �Jl(p (/ M,� All roof coverings to be Class "BTI or better
Owner ter authomsd agent Dem