04120032 C[1'YOFCUPERTINO
BUILDING DIVISION PERMIT k�CONTRACT4R INFORMATIONBUILDING DIVISION PERMIT INFOO RMATION F
Bu1lAINGADDRESS: SALLY LAUTEN & TONY WADE PERMIT NO.04120032
OWNER'S NAME: PERMITLSUEDATE
SANITARY O §OL NO.
ARCHITECT/ENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
iso LICENSEDCONTRACTOR'SDECLARATION
1 wrcby 70100)of
that 1 on(dad Bu under prov;d.s of CMpmr 9(commencing Job Description
m with Section 9IXXpof Division 3ofthe Busirmu and Professions Coble,and mylicenae is
'^?a in full farce and effect, s
,q? License Class lJe.g ADD 400 (DETACHED ART STUDIO Se ARCADE)
Z�kDem Contractor
Z;:
ARCHITECTS DECLARATION
zi a I understand my plans shall w used m public mcmds
JyU
':G� Licensed Professional
OWNER-BUILDER DECLARATION
00 I hereby v(firm thin I am copra from Nc Conuanm's Lignac Lew for the
O O following reason.(Section Wr LS,Business end vee de ons Code:Any city m county
$ which am issca a Permit m construct,alter,improve,demolish,m repair g any structure
prior hs its issuance.pursuant
requires the applicant for such rector'm cc a signed nammcm
e��mea
that beescial;wit pursuant to the provisions of the eBuiness Lit ems Law(CharmrY Sq.F[. Floor Area r� / 'Valuation
$ (commercial;stamps Sections andofDivisionr nfthceged exemton,AyVit Code)or (Q
Net k u ems b governorsapplicant
and the huh for be alleged exemption.Any it Penalty
of
Section 7031.5 by anry appliunr farapermitwbjecu the applicant acivil pentlty of ppN Number L Occupancy T e
not mom Nan Frac hundred dollars($500). R P Y YP
❑1,u..of the popery,a my em,am as with I.u their sole compensation,
will On Ne work,and Neauucmre is not intended arenetrd for..In(Sec.]BOC,Bear. R
and Professions Cada:The Commiserates Licem,Lew docs not apply m an owner or 3 5 910 011 . 0 0 Required Ins tl'as
property who builds or improves themon,and whodoessueh work himullor through his �+
own employees,provided Nat such improvements Re not bnmstded oraRered for sale.If,
however,the building or improvement is sold within one year of completion,Ne owner-
builder will he.the burden of pmvNg Nat he did not build or improve Toa purpose of
sale.).
VT,as owner of the property,em exclusively contracting with licensed ecovwmn to
construct the project(Sec.7044,Business and Profusions Code:)rhe Contracher-a Lt.
cense Law does not apply to an owner of property who builds or improves thenen,and,
who contracts for such projects with a contracmrp)licensed pursuant to the ConuRtofs
Llcenm law.
❑ l em ssemp�,�noos&,see/��—��� B k P C for this_remon
Owner sa jlr ) Date ZI W
KER'S COMPENSATION DECLARATION
1 hereby afRrto under penalty of perjury one of the following declarations:
have and will maintain•Certificate of Consent to self-h sum for WorkmenCompcn-
sa0on,u provided for by Section 37M of the labor Code,for the performance of the
work for whim this permit is issued.
❑1 have and will maintain Worker's Compensation Insurance,u required by Section
3900 of the tabor Code,for be performance of dta work for which this permit is Issued.
My Workeri Compensation Insurance carrier and Policy number art:
Carrier. Policy No.: _
CERTIFICATE OF EX EM MON FROM WORKERS' ,
COMPENSATION INSURANCE
CIMS aced.need no'w completed if the permit Is(moot hundred dollars(SIM)
or less.)
1 certify Nn in the performance of the work for which this permit is issued,I shell not
employ any persen in anymkrnC17sat Mc a Int to dm Workers'Compensation
Laws of California.Dat,— M/2 j n
Applicant
NOTICE TO APPLICANT.If.after making this Cenifi.el.of Exemption,you should
Income subject to the Worker's Compensation provisions or the)shot Code,you must
.JO forthwith comply with such provisions or this permit shall he deemed evoked.
'Z" CONSTRUCTION LENDING AGENCY
r
[-� I hereby affirm Oat them iscacal( amcommuctuan30 lending agency for the perfurmantt of
ai the work fru which this permit is iuucd(Sec.J099,Cl,C.)
W lands(.Name
az lenderi Add.
U Q 1 cenify Nu 1 lave mad this application and sum Nn she above information is
D.F coven.l agree to comply wish all city and county eininanm and sum laws reining to
0[> building construction,and hereby authorion representatives of this city to enter upon the
W awvememionedrropeny for inspection exies purpowhich m.
Cl. 12
(We)agree to save,indemnify and kap harmless the City of Cupertino against
Z in
costs and ea penseamit. may in any way eccroe against City
V z in.nseguencc of the graining of this permit.
'-" APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT Issued by: Date
SOURCE ' ONS
Signature ofAppbmanU, .� `/Lj)O S
Re-roofs
ContractorDam
HAZARDOUS MATERIALS DISCLOSURE Type of Roof
Will the applicant tar future building occ.Part store or handle hurudous material
u defined by the Cuperti.Municipal Code.Chapter 9.12,and the Health and Safety
,saLcom.SteuartYes 255J2(a)9 XT+" All roofs shall be inspected prior to any roofing material being installed.
�
Will the applicant or future wilding occupant den cgaipment or devices which If a roof is installed without first obtaining an inspection,I agree to remove
isv hanadaas air conumioanu sat d.fined by the Bay Area Air Quality Management all new materials for inspection.
❑Yes ro
I have mad the hazardous materials oequimmcnts under Chapter 6.95 of the Califor-
nia HC01N A SafctyCme,Seeutxss 255115.255J1 and 255)4.1 undcrsantl Nuif the wilding
does not currently have a emant.Nat it is my mafmnsibility m notily the occurrent of the
mqubrcmcn1, It eh n tpriarm;aaamanr.cenireamlar .n an. Signature of Applicant Date
�i P, CtA`� ti l(D 5
Own, a aethod.n agent Date All roof coverings to be Class "B"or better
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