05020181 CITY OF CUPERTINO 'R
BUILDING DIVISION PERMIT 41 Rib ATT(y1V ��
r?aLi.,y%au4, F^.?'v2 "^"• Tau^^JxYx3` .cu. Ly ;e4A:
BUILDING ADDRESS: PERMIT NO.
CUPERTINO CONSTRUCTION INC 05020181
OWNER'S NAME: PERMIT ISSUE DATE
1
NE: SANITARY C OL NO.
ARCHITECGENGINEER: BUILDING PERMITINFO
BLDG ELECT PLUMB MECH
t� t�
O o LICENSED CONTRACTOR'S DECLARATION Job Desc n
i� 1 hereby&Man that 1 am licensed under pm rasions of Chapmr 9(commencing
withSeefon7000)o'Divisi ofthe Busineasand Profeskim Co andmylicensee
a
in fu ad West �d}��j9g SFDWL-2 STORY (3907 ' LIVING)-)/
i g
Lee.
Glass 2005
B Dam _t f;—RCHIIECTCnII�ECoLARATION GARAGE 600 ' y� 005
I understand my plain Nall he used as public recnrm BUILDING
g ®u'L®I■ a
� Licensed Professional
OWNER-BUILDER DECLARATION ®J
I hereby o(Sw o that I ore exempt from the Contractor's Cs License Law for the
p o following mason.permit
7(n 1.5,Busie=s and w,moll Cade:Any City or county,
s$_� which requires s permit m u mwcL alcor,improve,de permit
i ri repair any twaum -
'�_g Sr Poor at he ississuance.
ensedprsu nto the the applicant far such Connetoitmfileaaigaw(Chned statement
ggSS<
(commencing
pursuant 70th)pro vision of the Connector's LionselJw(Chaprmf9 Sq.Ft. Floor Area Va411GOM 4.7
to them els emgwlNSet1fan70W)of ma hold far of Alegedaaand PrafevianaCOdC)l.tmn or yS�O'4tl
33 Nat he b cacmpl Ihemfaom antl Ne buss fm the al�lad esempdan.MY violation of
Section 7031.5 by any applicant for A permit subjecis me applicant to a civil penally of APN Number Occupancy Type
Am mom Nan five hundred dollars($500). 35705046 . 00
[:11,ma owner of the properly,m mp
my employees with wiles as their ale consallon,
will do me work arm thesuu=ure tarot intended at offered fm sale(Sec.700,Businev Required Inspections
and Profession Code:The Conuacwr's Lies.law done int apply to e ns an awner of q P
propeny who build or i mpmvm thereon.and who does am h work himself or thmogh his
own employees.provided mal such improvements arc not Inendnd or offered formaic if.
however.the building or Improvement uaold within aro yearof ompietion.the owner.
builder will have the burden of proving that he did n0 build or improve for purpose of
male,).
Cl 1, a owner of the property,am exclusively contracting with licensed contractors In
romrmet me project(Sec.700,Business and Profession Code:)The Com esetors Li-
cense law dors not appy in An owner of property who wilds or improv marine,and.
who contracts for such projects with aconments)licensed pursuant in the Convaetoes
License Law.
1 ore exempt under Sac. .B&P C far Nis ressov
weer Dam
WORKER'S COMPENSATIONDECLARATION '
I hereby aM m under Penally of perjury aro of the following declantimu:
I haw and will maintain a Cenifinte of Consent to selFinure for Workers Compen.
n ation.As provided for by Section 37M of On Labor Code,far the performance of the
work for which this permit is issued.
❑1 haw and will maintain Workers Compensation Inurana,Am required by Section
37W of Ne labor Cade,for the performance of the wink fm which this permit is issued.
My Worker.Compensation Inursnce carrier and Policy number art:
Cartier. Policy No.:
CERTIFICATE OF EXEMP ION FROM WORKERS
COMPENSATION INSURANCE
(Thissectinn need notbccompletad it the permit is fortune hundmddollars($10(y
nr leas)
I unify that in the performence of the work for which Nis permit is issued.I mall not
employ any perms in any manner so ss m becotneaubj-Eh"Worker"CompenNan
Laws of California.Data ws
Applicant "7 1.
NOTICE TO APPLICAMTf After making this Cen flute of Facmption,you mould
become subject to me Workers Compensation provisions of the labor Code.you must
v7. forthwith comply with inch provision or this permit shall he domed mwked.
Z y CONSTRUCTION LENDING AGENCY
[..r I hereby affirm Add dere 4a ConstmNnn lending agency for de Performance of
ori
the walk for which this permit Is issued(Sec,3097,Cih,C.)
Q Lenders Name
Z)z Lemm's Address
U0 I certify that I hew mad this application W sem that the above infomrNun is
tl+^ corms 1 agtx to comply with all city and county ordinances nd adds,laws relating to
SV" wilding construction,and hereby authodre representatives of that city or,enw upon be
W above-mentioned property for impaction purpos
a
(We)mg.to caw,indemnify and keep hrtmless the City of Cupertino against
yliabilities,judgments.casts and expose=which may in my way accrue against aid City
is consuenc
his permi.
APPLICANTeUNDERSTANDSof the Swung oftAND WItLL COMPLY WITH ALL NON-POINT Issued by: Date
SOURCE REGULATIONS.
��—• (' Re-roofs
Signature o icmVConwctm Dam
HAZARDOUS MATERIALS DISCLOSURE Type of Roof
Will tieapplicant or future wilding occupantame or hard.baalloas material
As darned by me Cupinuo Municipal Code.Chapter 9.13,and me Health and Safety
Code,Section 25531()7 All roofs shall be inspected prior to any roofing material being installed.
❑Y= Nu
Will Nc applicant m futum wilding occupant use equipment or devices which If a roof is installed without first obtaining an inspection,I agree to remove
it he'ramous Air contaminants ss defined by the Bay Area Air Quality Management all new materials for inspection.
vic1T
❑Yes &Nu
I haw mad the haraNmvs materials mquimmems under Chafer 6.95 ofthe Califon
ria Hcalm 6 SafetyCode.Section 15505,25533 and 35534,I understood that If the wilding
does not currently have A LLnlant,that it is my responsibility in notify tie accupemt of the
requimmenta which am be met pier "amuse orfs Certitude of Occupancy Signature of Applicant Date
owner emhodxtlagent Dae All roof coverings to be Class"B"or better
C