03110015 CITY OF CUPERTIN0
BUILDINGDIWNION PFRMTi ,ONTI�QCTORINFORMATION-,
BUILDING ADDRESS: ADF CONSTRUCTION PERMIT NOO 3110015
860 SANTA TERESA DR
fEER'sNAME: 6201 SHADELANDS DR PERMIT ISSUE DATE
EI SHAO 11 04 2003
4082819177 SANITARY NO. CONTROL NO.
ARCHm1C1`IENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
100 LICENSED CONTRd under
SDECons or CON
i I hcmby affirm that 1 am fOn Bu under provisions ors Code, 9(commencing - Job Description
.< with Section )of Division]of the Business and Professions Code,and my license is
< Lfulrauca fife f/�G p ADD 60 SQ. FT. (M.BATHRM) �)LT �F
j�Z
Lice Cl Lie.. R�
p Dam Conuen -
'Zt,��j ARCHITECTS DEC ION
W uL crscand my plans shall be vud as ip c meads
�WpN Licensed Profcssionel JUL 2C 2004
5 OWNER-BUILDER DECLARATION
P I hereby affirm chat I am exempt from the Conmi License Low for the
00 fallowing maxon.(Section 7031.5,Business and Professions Code:Any city or county BUI��g1Y 54000
S which requires a permit to consumer.alter.imve
pro ,demolish,or repair any shumus
iy poor ha its issuance,also requires the applicant for Such Permit o File a signed statement
�o that he is licensed parananuothe pmvi,bnaothe ConwcthriLicense Law(Chapter 9 Sq. Ft.Floor Area Valuation
(commencing with Section 7000)of Division 3 of the Business and Professions Cover)or 35613009 . 00
1�S Nat he is exempt therefrom and the tourist On,alleged exemption.Any violation of
Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of APNNber Occas Type
not mom than five hundred hall...(S500). umOccupancy YP
1,u owner of the property,or my employees with wages as their sole compensation,
will do the wars,and the structure is not intended or offered for sale(Sec.70s9,Business
and Professions Cade.The Conoamats License Law does not apply m an owner of Required Inspections
property who builds or improves thereon,and who aloes such work himself or through his
own employees,provided Nut such improvements are not intended or offered for sale.If.
however.Ne building or improvement is sold within one year of completion,the owner.
builder will new the burden of proving that be dial not Wild or improve fur purpose of
pia.).
1,as owner of Ne properly,am eashedwly contracting with licensed cunvecmra to
consumer Ne proje0(Sec.7049,Business and Profession Coder)Too Characters U.
cone Law docs nut apply to O owner of progeny who Wilds or improves thereon,and
who contracts for such projects with a conmaor(s)licensed pursuant to Our Commences
Lkonu Law.
I am exempt under Sec. ,B&PC for this reason
Data
WORKER'S COMPENSATION DECLARATION
I hereby affirm order Kathy of perjury ane of the following declarations:
1 haw and will maintain a Cenifeam of Consent o selginsum for WorkersCompen-
sation,as provided for by Section 37M of the Labor Code,for Ne Performance of she
work for which this permit is issued.
I ban and will maintain Worker's Compensation Insurance,as required by Section
3700 or the labor Code,for the performance of the work for which this permit is issued,
My Worker's pen aionllbiummica artier and Polity number im:
Cartier /ter Policy 0 — a 3
CERTIFICATE OF EXEMPTION WORKERS'
COMPENSATION INSURANCE
(This section need not be COmPlemd little Permit is for one hundred dollars 1$100)
or lard.)
I certify Nat in the performance of the work for which this permit is issued.I shall not
employ any person in any mannersn es to become subject to the Workers Compenatlon
Laws of California.Date
APPliam
NOTICE TO APPLICANT:IL after making this Ccnificam of Exemption,you should
become suhjcct m the Worker's Compcnption previsions of the Labor Code,you must
�z forthwith comply with such provisions or this Permit shall Ise deemed revoked.
ZO CONSTRUCTION LENDING AGENCY
�—t Ihereby arfirm Net there is a construction lending agency for the performance of
> the work for which this permit is issued(Sec.3097,Civ,C.)
11 Landers Nauru
= z Landers Address
U Q 1 comfy Nat I have read this application and scale that Ne above information is
ly Fcorrect.I agree to comply with all city and county ordinances and state lads mitring to -
C)V building convection,and hereby suthern<mpresentatiws of this city to enter upon the
erty
purpo
G shove-mentioned cost for inspection expenses
which m. ( t
(We)agree to save,indemnify and keep harmless the Ci ry of Cupertino against /
.Fi to inconsequnce of the granting
tsintl of this esmit. may inany way accmc against City
UZ APPLI ANN NDERmmin&of this Permit.
^' APPLICA UNDERSTA OS AND WILL COMPLY WITH ALL NON-POINT Issued by: Date
SOUR GULATIONS.
B
srg a5 pppliw tar aNt 0<2I fl ate Re-roofs
✓" HAZARDOUS MATERIALS DISCLOSURE Type of Roof
Will rhe applicans or Potum building occupant stem orhandle baeardous material
se donned by the Cupertino Municipal Cade,Chapter 9.17,and the Health and Safety
ndc,Schon 25532(a)?
❑Yes `X-1. All roofs shall be inspected prior to any roofing material being installed.
Will the applicant or future building areupam use equipment or dcvica which If a roof is installed without first obtaining an inspection,I agree to remove
It haaardous air contaminants as defined by the Bay Area Air Quality Management
issrin7 all new materials for inspection.
I have mad Or buicom is mamrialssyvirtments under Chapter EJS of the Califon
at.HOlth&SafetyCode,tenant hat2M5.25533
myrand25539. understands Oifup Wilding
dr not curt I hen a mnem that it is my responsibility m nnul'y the cecupant of the
irtmen ich mastbe t Poor to issuance his Certificate 0f a Signa[ Of Applicant Date
Owner , ad,ed gar, m All roof coverings to be Class "B" or better