03070161 CITY OF CUPERTINO -1 'wr�, R ' £ -ryr�� `� I ''.r
BUILDING DIVISION PERMIT �CONTRACTORANFORMATION.,�
BUILDING ADDRESS: PERMIT NO.03070161 3070161
HER'S NAME: PERMIT L'SUE DATE
T-RR DENNIS C' AND KATHERINE T
NE: SANITARY NO. CONTROL NO.
ARCHITECnENGINCER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
!00 LICENSED CONTRACTOR'S DECLARATION ) bDescri tion
F 1 hereby affirm that I am licensed under provisions Of Chapter 9(rooDescription
with Section lOf)(B of Division S of the Business and Professions Code.and my license is
In full to.and effect.
License Class Lac.0 NEW 2 STORY DUPLEX
it- °ate 7`SDECLARATION Contractor
ARCHITECTS DECLIVING SPACE 3209 SQ. FT. /GARAGE 566 SQ. FT.
Q4
i$ 1 undersmnd my plans shall he mica As public records
j
C LiconseJ Pmfcuional
3 OWNER-BU Apt from
DECLARATION
o Q y I nmaso alarm Nat I am escmpt from the Contractors :Any c law co the
O o following meant,permit
t1 onstr,Business and ere,do imn Code:Any tiny or county
P$ which its requires n permit a Construct,alma Improve,demolish,or repairanytawoom
Prior its lensed e.also pursuant
amgo theres ovas applicant forme such permiuuicensle ae Low(Chapter
that
commecing wispuntion70he pmvisionsofthe Comrades(a Littmcsaw(C Code)
Sq. F[. Floor Area VatllaCt�5b000
Z�N 'at he ise
(commencing wish Section and of,bouton 3 of the Alleged
Business and Professions Cmle)of h54
$ Natio is exempt therefrom and the bum for Ne objects
the
exemptim.Any l violation of
net...than
70315 by any identfor 4.($50Permit mbjecu the applicanuoacivil penalty of 3Qk?IIlgt.l @4er00 Occupancy Type
not mart Nan five hundred tlollers(5500).
❑I,As owner of the property,or my cmployces with wages As their tole compensation,
will do the work,and the structure is not intended or offered for safe(Sec.1014.Busiws
And Prefeuiou Code:The CA me.Liecnx law does not apply on an owner of Required Inspections
property who s.provi improves ch improve who Are
eseuch work Croffe onhrough his
Own employees,provided thinouchimprovements arcnot intended completion,
formic.r.
huilder ,Nebuilding orImprovement bholdwithin one year oft prove for Ne owner
builder will have the burden of proving Nu rte did not build or improve for purpose of
filt,)�-
'eWyl/,a owner or Ne property,am exclusively contracting wit licensed contractors to
convect,he pmjem(Sec.1044,Business and Professions Code:)The Cunmmtur's Li. /
cense law dins not apply m an owner or property who builds or improry Merton.and
who contracts for such projects with sconuanot(s)licensed pursuant to the Contractors
0 1 AM law. c0
❑lam comps r .B&PCfo Nis uo G/
Dale
ENSATION DECl1RATION
I ertby aRrm under penalty,of perjury one of o awing declarations:
I have end will maimalo a CMM(Kram of Continuo mifdnsue far Worker's Compete
cation,ss provided for by Section 3]00 of Ne Labor Conic,for the indmoname of the
work for which this perrttll is issued.
O I have and will maintain Workers Compemation Insurance,As Iequimd by Section
31110 of Ne Labor Code,for the performance of the work fm which this permit is issued.
My Worker's Compensation Insurance carrier and Policy number are:
Cartier: Policy No.:
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(This section need not M completed Kite fermi,Is intone hundred dollars($I00)
or less.)
I certify that in the performance of the work for which this permit is issued.l shall not
employ any person in any manner se As in become subject to the Workers'Compensation
Laws of Califomis Dam
Applicant
NOTICE TO APPLICANT:If,after making this Certificate of Exemption,you should
become anhjeet m the Worker's Compensation provisions of Ne labor Code,you mus,
�O forthwith comply with such provisions or this permit shall be deemed revoked.
Z� CONSTRUCTION LENDING AGENCY
I hereby aMrm that Nem is a convection lending agency for the performance of
,he.,it for which his perrni,Is issued(Sec.3099,Co.C.)
L 0 Lenticr's Name
Lentler'sAddreu
0 I comfy not 1 nave mad this application and some that the ahom infmmNun is
L(~ correct.1 agree to comply with all city and county ominances and stale laws relating to
�U building construction,and hereby authorize representatives of this city to onto,upon the
Y a above-momioned pmpcny for inspection purposes.
We,agree to ave,indemnify and keep harmless the City of Cupertino against
(n liabilities.ludgmeno.coss and expenses which may in any way settee against said City
J7 in consequence of Ne graining of this permit. 7
' APPLICANT tjD(DERSTA WILL COMPLY 10//1/05 ITH/,LL hfN POINT Issued by: Date
SOURCEARB�JU�kSrypp��/a
Re-roofs
S' nature o m Dam
HAZARD° S MATERIALS DISCLOSUR Type of Roof
Will tho applicant or future building Occupant atom or handle hawdous material
u defined by Ne Cupenmo Municipal Code,Chapter 9.12,and the Health and Safety
CoJc.Section 25532(x)?
❑YG All roofs shall be inspected prior to any roofing material being installed.
Will the applicant or future building occupam esu equipment or Jcvicos whim If a roof is installed without first obtaining an inspection,I agree to remove
it havardnw air contaminants As JcOned by the Bay Amu Air Quality Management all new materials for Inspection.
uicR ,u
0Ycs /IRAN
I have mW the hoarthms materials requirements under Chapter 6.95 of the Califon
Am Health&Safety Code,Sections 25505,25533 end 25534.1 undorsmna Not if Ne building `
0.not conemly how tet.Out it 0 m es uihillny m nnafy mmu ant of the
myuirtmcn.which res ra CCNOca of mpanm. Signature of Applicant Date
�0 is 03
er m amho'c n ata All roof coverings to be Class "B"or better