04110070 CITY OF CUPERTINO d"'
BUILDING DIVISION: .: TERNUT `O TR tri R TNI U:�RMATIUN r
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BUILDINGADDRESS: PERMIT NO.
04110070
R'S NAM - - - PERMITLSUBDATE
ONE: SANITARY 110t Uniko-1.NO.
ARCIADECTIENGINEER: .BUILDING PERMIT INFO
BO BLECT PLUMB MME H
LICENSED CONTRACTOR'S DECLARATION _
i I hereby ff..Wel l am lhoaadamidbrpmMsiom of Chapter 9(mmmelrtinr - .. Job Description
< with Section 7",UDivision 3dftim Bum.and Professions Code.and!my Ike.is - ,_•• y- ,
<S mflllfarceandettecl.
qq'(az LiammCtase - Lm:a ADD ,1001 (CLOSET) INTER. REMODEL -
t�_ Dau - Contractor
ARCHr1ECTS DECLARATION
I undcmund my plane shell W used As public reemda -
333� Licensed Professional
OWNER-BUILDER DECLARATION C ��
5i I hereby affirm Wet 1 em exempt from We Contractor's License law for We 5hq
Ra o following mason.(Section](131.5:Bwim ew end Pmfeusimis Cade:Any city or county MAI
1
$ which acquires a permit in eonnr.ct,alcor.barrow,demolish,.r repair any cmeturt _ �/G /.i ,
Fz�^ poor to its Issuance.arm requires the applicant for inch permit to rim a signed mWment' l� -
g < that he is licensed purswnt to the provisions of the Contractor;Umam Law(Chapter 9
Sq.,Ft.,Floor Area ���.�. ••Valu ton
gSCD (commencing wild Seman 70D0)of Driehaus 3 of the BWnau end Profeuma Code)Or
3 a
Win be is concept Ihert(rom and the hash for We alleged exemption.Any A.Wh n of
Section 7071.5 by arty applicant for a permit subjects We applicant to a av0 penalty of -3.-A•DI.L.Td,01#1e�0 OccupalfcY Type
Out mart Wen five hundmd dollars($500). - .7T'YP V'V'7lll//``tt11'LL'"'
❑1,ax owner cribs property,or my employes with wages u Weir sole compensation,
will do the nark,end Memoriam umtiaeaded molfered forsam(Sec.7044,Business
And PmreWaas Cade:The Canumudel Licene law dna.nal apply iom ownecaL - - Required Inspections ' '-
. . propenywhobuildmrireprons thereon,and wbodaeamchwmk himselforthrough his
own employes,provided dut ouch impmwmmu ammtimmndedw oRemd fm Wa lf.
howew.We building or improwreent Is mid within ane year o(compledon.the owner- -
Wilder will ban We burden of proving thu be did nm Wild or Improv for purpose of -
;who
s Owner of the property,em exclusively contracting with licensed members W
ct We Project(Sec.lMa,Business m0 PofeWoa Cotler)Te ContrsetoYs Li-
n
i• - -
Law doh not apply m an owns,of property who Wilds or Improves Wnmm,and
ontrac nm Jam wiNecontrantort0licenxd punwnitothe ContnnoYemla e m under Se. ,Bk PC fm this nom,
rATIECI.kRAT10NbeacbYaRnmunderpesaltyafpajuryamof call 'ngdailicamiom:aveand will malnuina CeNficata of Coasentseself-iaurt for Warkefs Campm-
sation,a provided for by Section 3700 of the Labor Code,for We performance of the
work for which this permit is isswd.
❑1 ban and will maintain WmWx Compensation Insurance,as required by Section - - - -
3700 ofmc Leber Cade,for the performance ofthe work for which this permit biased. -
My Workees Compensation lnmnnce carrier and Policy number am: -
Cartier. Policy No.: -
CERTIFICATE OFEXEMPTION FROM WORKERS' -
COMPENSATIONINSURANCE
rlTb maim need not becompleted If the permit is f.rone hundred dollen($100)
or lass)
1 certify that In the performance of the work for which this pmmit is formed.l Mail not
employ any person in any manncrm as to become mbject to We Worken'Compenmlon .
Laws of Calif carie.Dau
Applicant -
NOTICE TO APPLICANC IL after making this Certificate of Exemption,you should
became Object to the Worked Conammation previsions of the lahm Code.you newt
,J O forthwith comply with such pravisions at Nis permit shall be decreed ranked.
,Z.,y CONSTRUCTION LENDING AGENCY
f, Iherebya ice let Wert is.construction heading agency fm the perfmmance of
y' Lha wank far which this permit Is!Aimed(Sec.3097,Cl,C.)
a Q Unclels Nurse
.`D z LeadetsAddress
U Q I molly that 1 en reed this application and sum that the&bon Information is
{C.F COMM.l agree to comply with all city and county ordinances and cute Iowa muting to
OU building consuuction,md hereby Authorize represcamim of this city to enter upon We
W mon-mentioned pmperty for Inspection purposes.
(We)agree in an,indemnify and keep harmless We City of Cupertino against /t 04
II.MlI As,judamc u,cosu andexpe"•^•which may in my wyattme agalM WO City /
t)7 in con pence - ni of this permi - -
.T^w'i
AP PL AM' N RST NOS AND W COMPLY WITH A/IS.NON-POI Issued by: Dat
l�
11 1f Re-roofs
nate fA MmVConuactor Data
HAZARDOUS MATERIALS DISCLOSURE Type of Roof
Will We applicant or fumm Wilding occupant core or handle hvndms materiel
As defined by the Cupertino Municipal Code.Ceptor 9,12,and the Health and Safety
.Samoa 25532(e)7 All roofs shall be inspected prior to any roofing material being installed.
Yrs
Will the applicant or future Wilding oavpmt um equipment or dcvima which If a roof is installed without first obtaining an inspection,I agree to remove
mit heard...air conmrmanu as defined by We Bay Ana Air Quality Management all new materials for inspection.
Din 0
❑YIN u
I han mad We esaNnusmceriels requirements underCepurd.95 of the Caliper.
ria HcolthB:Sefcty C 'ore 25515,25537 d25531.1s,adcreumalthciflhe building
dao not tly w .that it h my _.i,,,,,
m no the ore t.f We
acgwacmcn i be Ipd maraCutirm,te0 apaney� gnatureofApplicant Date
l �� Z �F All roof coverings to be Class"B"or better
art art INN 'xc agent Date