04120058 CITY OF CUPERTINO
BUILDING DIVISION PERMITCONTRAC`TORINF,,ORMAThQN
BUILDING ADDRESS: NICE Se RIGHT CONSTRUCTION 6""04120058
121R11 qAM 77.PNANDC)
0' NER'S NAME: PERMIT ISSUE DATE
E:
SANITARY O. CONTROL N0.
ARCHITECDENGINEER: B{]UNG,PERMIT INFO
E PLO =1
000 LICENSED CONTRACTOR'S DECLARATION °�
u 1 hereby affirm Nn I sm licensed under provisions of Chapter 9(commencing Job DescriIIOn
Z1� with Se<tion]gslp o(Division Sof the Business and Pm\ (s Cyodc.anQmylimosoci l 9�'iV aj00aa
< inN^Iraraanaerc«� L/ 1 S Oy SFDWL-2 STORY (3843 L NG), ( o
i Lie seClass Lic.I
Dam cant amor GARAGE 494 S Q. FT. ��
ARCHITECTS DECLARA Ods IA]'}q�� [��
jW I uMerganJ my glare shall h used u public meurds '11.f\L gl
n IUf[�7�
;aw Licenced Professional
5 OWNER-BUILDER DECLARATION
I thereby arm that I am exempt from the,Conlmmors License Law for the
E:00 following mason.(Section 7071.5,Business and Profcniam Code:Any city or county
m which requires a Permit to construct,eller,improve,demolish,an repair any structure
prior m its issuance,allo inquires the applicant far such permit to Glc a signed statement
< that be is licensed pursuant the provisions of the Conlmcmr's License Law(Chapter 9 Sq.Ft. Floor Area V gs(Isso 00
(Cox Z5
y N$ that Zn exempt creSectian]000 O Division r the al Busegeineuand Propon.An ions CMc)of .
_
that he u exempt therefrom and the baso for dte alleged excerption.Any violation of
Section 7031.5 by any applicant fix a permit subjects N.applicant o a civil penalty of APN Number Occupancy Type
not¢ort Nan love hundred dollars(5500).
I,sa owns of the pmprrty,m my employers with wages u tle'vsole compensation, 3 5 7 15 G-9�
will da the work.and to structure is not intended oroRered forsale(Sec.7W.Business !� Required Inspections
and Professions Cods:The Contrazlars License Law does not apply b an owner of q p
propcnywW builds orimpmves Hereon,and whodacasuch work himulfor through his
own employ=,provided Natsuch impmvemenu are not intended oroRcred forsale.IL
however.the building or improvement is sold within one year of rnmpletion,the owner.
W ildcr will have Ne b ode.of proving that ha did not build or improve for purpose of
ting).
Co L as owner of the property,B siness add conessi:..with:)The Ccuneactms to
Co.,., it sin (Sec.to . Rosinessandny who Wild.
Code:)The Coneazlolsnd
cense Law docs not apply loan owner of progeny who sed p or improves Neuron and
who contracts for such proKcu with a convazmr(s)licensed pursuant to the Coneacloh
License Law.
Tam J
❑ exempt under Sec. ,BkPC for His rcuon
Dale
WORKER'S COMPENSATION DECLARATION /
1 thereby affirm under penalty of perjury ane of the following declaration
am and will maintain a Certificate of Consent to self-insure for WorkdsCompm-
satiti ,as provided for by Section 7700 of the labor Code,for to performance of the
work for which this permit is issued.
❑1 have and will maintain Worker's Compensation Insurance,as required by Section
7700 of the Labor Cod.,for Ne performance of Ih.wart for which this p umil is issued.
My Wortcrs Compemation lnsu ceanrierand Polity number are: '��[—
Cartier. Policy No.: �0)�Z�1
CER IFIL OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(This section need not W completed if the permit is foronc hundred dollars(6100)
or less.)
1 ser ify Hat in the performance of to work for which this Permit is issued.I shall nor
employ any person in any manner so as to become subject to the Workers'Compewtion
Laws of Califomia.Date
Appll.am
NOTICE TO APPLICANT:If.after making this CeniOcate of Exemption,you should
Immune subject to the Wagner's Compensation pmvisiom of Ne Labor Code,you mug
.J 0 forthwith comply with such provisions or this permit shall W rimmed revoked.
Z" CONSTRUCTION LENDING AGENCY
I bomb affirm Nat Nem iso co.,ino kndin
F Y :agency for the perfurma col
tYi rhe week for which Nis permit Is issued(Sec.7091,Ci,C.)
Cfenders Nam.
�,z Leaders Address
U Q 1 cenify Nat I have road Nit application and sate that the above information is
IB, P crena 1 agree to comply with ill city and county ordinances and sate laws relating to
p V Wilding construction,and hereby suNonne representatives of this city m enter open the
r ,, ahovctiesJum.d sat.csi fon ie ponic.es purposes.
F' 1 (We)agree to save,indemnify and keep harmleas the City of Cupertino against
N inconsequnce of the granting
of this expenses may in any way assure againatsaid Ciry
v Z APPLICANT'e ND RSTANDS AND WILL
Issued b Date
r. APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT y;
SOURCE REGULATIONS. Re-roofs
S' nlimrt of ApplicaneComgcm( U /Date
HAZARDOUS MATERIALS DISCLOSURE Type of Roof
Will IW applicant or figure building Occupant gore or handle ha,a out material
as defined by the Copeman Municipal Code.Chapter 9.12.and the Health and Safety
704.,Can,Seen..25532(a)? Na All roofs shall be inspected prior to any roofing material being installed.
❑Yes
Will tW applicant Or future building Occupant use equipment or devices whim -If a roof is installed without first obtaining an inspection,I agree to remove
C,r'.oOonxCd
harardoua air contaminants ss defined by the Bay Area Air Quality Management all new materials for inspection.
rie,7
c3Yes )E No
I have read the hva doses materials requiremcna umkr Chapter 6.95 of the Califon-
colN4Sofhey Code.Seniors 2!1%5.25577 and 25574.1 undersand Nat if lM Wilding
oat currently have a tenan.Nat it u my r«poruihility m madly the occupant of Nc
immcas which must be mel poor m issuance ofa Certificate of Qcupancy.
1/�J)1S --/��,_� 1 Signature of Applicant Date
— as.m Date All roof coverings to be Class "B"or better