05010037 CITY OF CUPERTINO `
BUILDING DIVISION PERMIT ,"C"0,, 1SO AgOR TN'F'()1i'MxpoNV"
Bu1LDING ADDRESS: R. K. BERRETT CONSTRUCTION ReTNo05030037
6A6 2AN 71-IA-N RD
OWNER'S NAME: PERMIT ISSUE DATE
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SANITARY OL N0.
ARCHITECffENGINEER: BUILDING PERMIT INFO
BLDG O PLUMB MECH
AOZp LICENSED CONTRACTOR'S DECLARATION MJob Description
M'�Yr 1 hemby affirm that I am licensed under provisions of Chapter 9(commencing
U wWt Section 7(00)of Division 3 of the Business and Professions Code.and my license is
ern Me der 1CS8 ) ADD 443 ' (MS .BED KIT. ENTRY) & REMODEL
License ClCI - hl I C Le.N / /
3Y�$ Dam Commumor''aTK�Ujimt5Ii— RES . & BASEMENT/REROOF
Y S ARCHll the u S DECD RATION _
rt Syu I understand my phos shall M uxtl u public rtcnrtls
30� Liccoxd Pmfcssional .
OWNER-BUILDER DECLARATION
Tt 1 hemby&M m that I am cmmpt ram the Contractors License Law for the
t O O fallowing mason.(section 7831.5,Business and Professions Cade:Any city or county
+�$r which acquire a Permit m conswct,alar.improve,demolhh,of mpalf any sanctum
s,Zt' priori is isruame.aho requi.theapplicant fmsuch permluo file asigncdsmemem
x C
that Ise is licensed pursua i to the provisions of the Contractors License law(Chapter 9 Sq.FL Floor Area Vat lltg�0 0 0
�$ (cmnmencing with Section 7000)of Division 3 of the Bnainmand Professions Cnde)or Y
that he is exempt tiartfmm and the bah for the alleged a.-mp ion.My violation of
Section 7031.5 by any applicant for a permit subjcca the applicant to a civil penalty of APN Number Occupancy Type
am more then Ove hundred dollars($500).
01.So owner of the propeny,m my employ.with wage a show.1.compinttion, 34218025 . 00
will do the wort and the swmum hat intended or offered rte Sale(Sm.7044,Busirras Required Inspections
and Professions Code:The Contractors Liam&law d.sol apply m e an owner of q P
propeny who buildsorimprows thereon,andwho dmnmh work himself or Waugh his
ownemploy.,provided that such improvemmu art notintendcd moReted image.IL
however.the building or improvement is sold within oro year of cmnpletion,the Owner.
builder MR have the burden of proving that he did not Wild or improve far purpose of
ale.).
❑1,as ow.of Ort pmpenY•am"clusively contracting with licensed contnnoa to
construct the project(Sec.7044.Business and Profesvufa Code:)The Contractors Li.
scrim Law does not apply an an owner of propeny who Wilds or improves W conn,and
who contacts for such pmjcm with a corm ctm(s)licensed pursuant mdse Contractors
License law.
C] m laexempt under See ,B&P C fur tha reason
Owner Date
WORKERS COMPENSATIONDECI.ARATION
1 hereby&from under penalty of perjury ane a:of the following declarstim
—� ave
and will maintain a Cenificam of tomcat m aclf-idaa rwWodrers Compete
&tion,as provided fm by Station 3700 of the boor Code.far the Performance of one
work for which this potash is laced.
❑1 have and will maintain Workers Compensation Insurance.as mquired by Section
370D of the Labor Code,for the palls m loo°f Ne work for which Nis permit is issued.
My Workers Compensation Inannce artier and Policy number art:
Carrier. V 1'Rg,IW LA S , PolicyNo.: 6OSOoo�)4Af
CE FII ;';EOFEKEMPTONFROM WORKERS'
COMPENSATION INSURANCE
(Thhaection need notbecomphoed If the Permit lsrmonce hundred dollars(S100)
or l..)
1 ceoify that in Bre performance of the work for which this Permit Is Issued.I shall not
employ any person in any reactor an as m became subject to the Workers compensation
Laws of Ctl(Ioais Data
Applicant
NOTICE TO APPLICANT:If,afar making this CenlOute of Exemption,you should
become subject an Ne Workers ComPCm ation provisions of the,labor Code,you most
0z foMwith comply with Men Provisions or thh permluhall x domed revoked. ..
,zm O CONSTRUCTION LENDING AGENCY
F I Wreby offttm that there h a construction lendingagency for the iacdoomanm of
(Ym7 Rae wart far which Nis Permit h bound(Sec.3097,Civ.C.)
0.i Q Lenders Name
Z)z Lenders Address
U Q 1 sonify Nn I have and this application aad state that the above information II
(y FCOMM 1 agree to Comply with all City and county ordinances and sate law misting m
U Wilding construction,and hereby authorise representatives of this city to color upon the
W ahove-mendoned property for inspection purposes
(We)agree to ave,indemnify and keep harmless the City of Cupertino against
y liabilities,judgmental,cord and Captions which may in any any seems against aid City
t„)7 to conxitanee ofthgranting of this permit.
r7 APPLICANT U RS ANDS AND WILL COMPLY WITH ALL 9
NNNQQQN.PO)NT Issued by: Date
/^ /
SignatureofApplian naactor T� 6 /LElAte Re-roofs
HAZARDOUS MATERIALS DISCLOSURE Type of Roof
Will the Applicant or future building occupant start orhandlc haandous material
So defined by the Cupenina Municipal Cade,Chapter 9.12,and the Health and Safety
Cole.Section 255324)? snn All roofs shall be inspected prior to any roofing material being installed.
E]Yes )n No
Will tW applicant or future building Occupant use equipment or devices which If a roof is installed without first obtaining an inspection,I agree to remove
.,,ardours atr coommiamte as dcOncd by the Bay Arca AM Quality Management all new materials for inspection.
uin7
Cl Yes JRNu
I have mad the hmmdsms materials requimmcna under Chapter 6.95 ofthc Collier,
nia Health&SaretyCode,Sections 25505,25533 and 25534.1 undersand that It Nn building
does rat torten now a neral Nm It h m rcepoosihlllly m nntity the mevpmt of the
fe9aI.,I' sirs a Ipriarmla a)rcgiBfamafOfea ry�e� Signature of Applicant Date
6 9
owner af.nmamnd seem Dila All roof coverings to be Class"B"or better
L'