04050027 CITY OF CUPERTINO
BUILDING DIVISION PERMIT �di�r� dRs1IVk' lir
BUILDING ADDRESS: STEVE NAN CONSTRUCTION PBRMIT"040S0027
OWNER'S NAME: - PERMIT ISSUE DATE
MEI
IEo SANITARY0. OL NO.
ARCHITECTIENOINEER: BUILDING PRRMIT INFO
BLDG ELECT PLUMB MECH
o o LICENSED CONTRACTORS DECLARATION
1 Womy often Net 1 Me licensed under previsions of Chapter 9(commencing Job Description
with section 700U)rfDiA.km 3 of the Buns ofeaso s Code,and my It...is
1 s. �11ffft+,m from SFDWL-2 STORY (LIVING 3 , 772)
OR Lo7 lic.g r
Dave a
cemrmr GARAGE 429 S Q. FT.
ARCH 3
'�11 IUMcrnand mypWsmWl be uadsa recr,tls
u
u Liccnai Professional
5ct Oat lam exILDERempt
DECLARATION
I hereby.(firm o n I em exempt from Ne Cssion Cc :Any c law for the
$o following moon.(Section]oma Business n. and improve,
duiuu Crdc:Any Illy structure$Pi which requires•e.also re ansuuc4 alar,ire prow,demolish,or mash ed suucmm
priamits iuusncc,alu tto the previsio of for such Conuscmitwnensele a,Law(Chapter
alua
that he islicensedpursuant totheof Division
of thehe Busclmhnd PreclAw(Chepler9 Sq.Ft.Floor Area Vee gT06 C,
5s danmcncinemptm Section7M)and
Divkslon3,(the Business abort. yvi Cnm)or vT
Nat he b exempt thue(rom and tie bub for Use alleged exemption.My violation of
Section 7031.5 by any applicant for a permit subjects the applicant in a civil penalty of APN Number Occupancy Type
not am Nu five hundred dollen($500).
❑I,uawnerof the property.or my employees with wages as their rob empenn8on, 35910004 . 00
will mman MmLand dmammaml,not intended moffered far axis(Sec.70".Bumum, Required actions
and Profestlom Code:The Contractors Liana e law does not apply m an owner of q p
own Property who builds orimponvas thauch improvements
and who deeumhwoke h roffenr Mough his
.
ownemployes,paWtled prove impre id wit tie not IntendedmoRertd Ire ala U,
Wildcrhoweveollha the Wildingtebrden of pmenturomeWinom year of Improve
on.for themvrcn
bulkier wiU have the burden of paving Nn he did test build or imprme fm purpose of `
tile.).
</ L2
em L as owner of the property.,B sinus and Prorating with:)The
eConahuwn m
c m La the canon apply
to n Business and Professions CakO The em daromri Lid j
ave law dans not apply je ts mvntr of property who builds orimprow Centra.sad,
who.Lam for such prejeeu with a eumuaRq licensed pusnt m the Contractors
V
Liana law. v yds
❑I un exempt under Sec. .B&P C for this moon v
Owner Date-
WORKER'S
amWORKER'S COMPENSATION DECLARATION
I hereby aRrm under penalty of Perjury can of the fallowing decimations!
Inve and will mainuin aCertifiate of Consent in self-insum fm Wo kea,Comport-
wion,u provided for by Section 3700 of the labor Code.for the perfomeme of Ne
work for which this Permit is issued.
❑1 have and will malnuin Workers Oompensauon Insurance,as required by Section
3700 of the tab"Cade,for the performance of the work for which this permit Is issued.
(My WoorkeSes vC�o�'mmype//—nsation Issuance artier and Policy num ram:
OviA —:5 A,m,_ Poli TEOPdWQOM WORKER '
J CERTF COMPENSATION INSURANCE
(This amlon nod tmlbetrmplewd If Ne permit Isfmrm hundred mil.($I W) '
nr low.)
1 ceNfy that In the Parr amane sur the..,it for which this Permit is Wed.I shall not
employ any person in my mune,an a in become subject to the Warlari Compensaden '
Laws of Cmifomie.Dow '
Applicant
NOTICE TO APPLICANT:If,after making this Certificate or Exemption,you should
become subject m the Workers Compensation provisions of the talar Code,you mum
,J Q forthwith comply with such previsions or this permit us][be deemed mvokcd.
z CONSTRUCTION LENDING AGENCY
[�4 Thereby aRren NO Nem is cosstmction lending agency for the perfetmamc of
(Yi> the work for which Ws Permit is issued(See.3097.Civ.C.)
W Q Landers Name
=z Ianmrs Ames _
U Q I certify that I have read this application and mw Net the above information is
U, corms I agree In comply with all city and county ordinaries and state Iowa miming w
0 building construction.and hereby mthodn ommosmuuws of this city m enter upon the
W ahovcmenumwd property for inspection purpoaa
(We)agree In ave,indemnify and keep harmless the City of Cupertino against
y Ilabllitiu,fudgramw,cats and expenses which may in My very aame against Said City
L)'J' in consequence of the granting of this Permit.
rr APPLICANT UNDERSTANDS AND Will![.COMPLY WITH ALL NON-POINT Issued by: Dto
S URGE REG ATIONS 7
Y� Re-roofs
um ofApplic HAZARDOUS MATERIALS DISCLOSURE Dow Type of Roof
Will tier applicant or future building meupm t mom w handle hazardous mawMal
a deMcd by the Cupertino Mu impel Code.Chapter 9.12.and the Health and Safety
Cam. _l Yea 35532(a)7 All roofs shall be inspected prior to any roofing material being installed.
_l Yea
Na
Will the applicant sur rut building occupant use equipment sur devices which If a roof is installed without first obtaining an inspection,I agree to remove
7ii.'1H!lth&S&fmyCodc.ScWmm
amines ail conuminanIo twfrned by the Bay Ama Air Quality Management all new materials for Inspection.
R❑YesSsIhavcmWthehastdnus No
wmals rcquiwmenu under Chapter 6.95 sur the Califor•
505.25533and2553/.lunkrsundthmifdc building
s not currently haw a mnsnL Nat It w y ramensibkltry ue sadly tier mcume t ofore w hmumbc m ora nartmrnanincateorOccupancy. Signature of Applicant Date
ncr onmhorir<d agent Dam All roof coverings to be Class"B"or better