04110075 CITY OF CUPERTINOaax +°x#':•M '� ^ rt 13 " 342 a A - - -
BUILDING DIVISION PERMIT ucC94 TRACTO NFA; h'fA'
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BUILDING ADDRESS: PERMIT NO. '
04110075
ER'S NAME: PERMIT ISSUE DATE
ONE: SANITARY C OLNO. '
ARCHIECDENGINEER: - BUILDING PERMff INFO "
- BLDG D PLOD
,+fop LICENSED CONTRACTOR'S DECLARATION -.sob.Description '
1 bomb affirm ftt 1 am Ihanecd under providow of CWpmr 9(mmmeming - - - .-
with Section)0qB of DlvWan3of the Burinees uW Profeuioes Code.and mylicenm4
y in full force and effort. r
Licenmclw Lie. REPLACE KIT. CABINETS/WINDOWS/PATIO DOOR
n q Dau Comecon, - -
W ARCHTECI`S DECLARATION
77 1 uMenumd my plane atoll be used u public nxorN
?Or^ Liccvcd Pmfamoved -. .
3 OWNER-BUILDER DECLARATION - - - - - -
I I hereby affirm that 1 am mu mpt from But,Conuattor's License Law far the - - -- - -
i ao following mama(Seed..71313.Business and Prefasmom,Cade:Any city or county
X S E which nequima a penult to cone...,aller.Improve,demolish.or repair my structure -
prior to its issuance.alto requires the applicant for such Permit to rile a signed motamml Val I On
=� that he is licensed punuanuo the provisions of the Conuscmri Limma,Low(Chapur 9 Sq.Ft.Floor Area .. ,
F D
y '
(commencing with Section r the eneuand aM Cod)w
dol he Is a dremfroan and the basis fm the alleged exemption.AnyeNun of
Section h1.5b any ppdpermit Subjects e.ppnaantto.cLitpe..uya
Occupancy TyPe
not momthenflnhundred doll..500. 34V=?*PA#e40
_.
❑'1,as owner.f cis propeuy,army employees with wages as theirmle compensation,
will do the work and the structure is notlnanded oroRered foraale(Ste.7044,Business '.Required Inspections '
and Profession Code:no Contractor's License Law does not apply m an counter of q P '
. . property who Wilds orimprowthemon,andwhadoesmeh work Mmselfarduvugh his -
own employees.provided lhmanchimprovemanu am mat butchered oraRered(maw&If.
however,she building or Improvement ismid within ore year of comple an.the ounce.
builder will how W hundm of proving drat be did Mt build or improve for purpose of ,
;ham
/
Avner of the properly,am exclusively and
cwum5ing with:)Th ed unmoor'.a ^
t the es not (See.soda, rner of and property
who
Cade:)The C,Vamem. d
w Oma not m m owner o!Properly who WIIds or improve thensen.and. -
La tafonucb pmjeeu n'iN acontaanortel0amed punwmathe Conuntofa ---- - - _
law.
empt der se .BkPCfarthismason RRE.R'S C FENSATION DEC ON
mbY alarm under Moody of perjury am of the following declarniam:
and will maintain a Certificate of Consent to self-Imam for Worker's Comport- ..
sector,u provided for by Section 3700 of the Labor can.for the Performance of the
work for which this Permit Is wood.
❑1 how and will maintain Worker's Compensation Iwmanoc,as required by Section
3700 of NC Labor Cade.for the performance of Loa work for which this permit is Lund. -
My Wmace.Compensation Iwunnee artier and Policy number
Cartier, Policy No.: �-
CERTIFICATE OF EXEMPT10N FROM WORRERS
COMPENSATION INSURANCE
(Thr senior need net he completed lion Permit Iefmanehummaddolian(5100)
or hook)
I cenify that in Lou part....of this.oh fm which this permit is iumd.I shall am
employ any porn In my murmur.u he Woman subject to the Worsen'ComPeesadon
La...f CW rmah.Dace '
Appllwnt
NOTICE TO APPLICANT:IE afar making this Certificate of Exemption,you should
become subject be the Worker's ComPewntion provisions of the Labor Can.you mm
.,O forthwith comply with such provisions m Nis Permit shall W deemed revoked.
y CONSTRUCTION LENDING AGENCY
[••, I hereby oirm that drum is a comtmclion lending ape.,for the Performanweof ,
a> the work in which this permit Is issued(Sec.3097,Ci,C.)
OW.Q Undoes Name
z Iandoes Address
J 0 1 certify that I haw reed this application and sou that tone%Ww information IS
f comet I agree to comply with all city and courtly ordinances and eau Ism relating he
0U building canmadon,and hereby anchorin representatives ofdtis city manta upon the
{i7 above-mentioned property for inspection purposes
a (Wol same a saw,indemnify and keep bounden;the City of Cupenim against
fjl IlaNlities,Judgmcnu, sat sed saps"•"•which may in my wayaocme sgaiwl said City
U z Ace
PPLICANTeUr ERSI M NDS AtNPe W t CO LY WITH ALL NON- HT ISRUed by: Date
SOU REG ATI S.
L Re-roofs
Si core Appli,onvCmarmt Do
HAZARDOUS MATERIALS DISCLOSURE Type of Roof
III the applicant or future building occupmt atom orhandle hsnNous material
dcOnad by the Cup union Municipal Code.Chapter 9.13.and tire Health and Safety
e.Roche.2553x(a)7 �[' All roofs shall be inspected prior to any roofing material being installed.
❑Yes jy Nu
Will the applicant or future building occupant use equipment or devices which If a roof is installed without first obtaining an inspection,I agree to remove
mit hamNow air canuminanu es defined by du Bay Area Air Quality Mmagcmant all new materials for inspection.
District? 33��
❑Yes ®Nu
the re eh and(((((ma�4��4malerials c immenuundarCNpur6.95ofNe Caliror
lirw.hilkS tic .Sa9au 255052513 uW25334.1undanwed des lfthu Wilding
decorate u nt1Y h a anmt that' ribilhY a mdfy da oceuPant of du
mq.ireme .hie .Rbemet lit .an ancnr.aar r' Signature of Applicant Date
Ow r audroriacd esent au All roof coverings t0 be Class nBn or better