05040018 CITY OF CUPERTINO
BUILDING DIVISIONpEt Ijj�jq' .�CONT12AGTQR INFORMATION
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BUIL DING ADDRESS: STEVE NAN CONSTRUCTION PERMIT NlOS040018
OWNER'S NAME: - FERMITISSUBDATE
Y.M.
E; SANITARY NO. CONTROL NO,
(408) 203-3933
ARCHITECTIENGINEER: BUILDING PERMIT INFO
ELLD0 EO MIL!?
+�00 LICENSED CONTRACT'OR'S DECLARATION
IOb Description+I 1 hereby affirm Net i an liceprovisoes of under provisoof Chapter 9(Commencing
IN Section 70p)afDivison 3 of dae Business and Profudan Cade.ape my license u
into
fora and ercect.
"'z LlaamCau _ Lic.a c REVISON--ADD EXTER. .DOOR
g' Dam Camaerar NO NEW PERMIT ISSUED/ORIG. #04050027
HIIECTS DEC
�i 1 understand my plans shall F.used u public records
i sed Licensed Professional
OWNER-BUILDER DECLARATION
I Money aRmt No I on esempt from the Conlsenars License Law for She
o o following mason.(Section 713I3,Busirc..and Protesson Code:Any city On Cony
$ which mqu(m a permit to Conwnct alter,improve,dcmol W.as mpWr any smic u ,
Prior m its issueace,al,a requites Our applicant for Such permit to rile a signed statement
< too he is licensed purwmttothe provisions ofthe Common's 6fcenxLaw(Chapter 9 Sq.Ft. Floor Area ValuatsaT000
8 (commencing with Section 7000)of Division 3 of the Business and Profa(nn Cuts)or
exempt 33 that he is IMmfmm and the haus for the alleged eximption.My violNon of
Section 7031.5 by any applicant for a permit objects the applicant m a civil penalty of APN Number Occupancy Type
not mom than five hundred dollars($500). 35910004 . 00
0I,uawrorofdepmperty.omywploymwINagesu Nabteleampe don,
willdothewak.andNenrueu¢mnotintended"oReredfar make(Sec.70aa.Budrcss Required actions
and Pmfasdom Code:The Cma acmfs License Law dm not apply m m Motore Inspections
of q p
property who Wlldsur Improves Nemon.andwho daesauchwark himselforNmugh his
own employees,provided than such improvements are not Intended"olfined forsate.If.
however.to building or improvement is sold within one you otampledon.Ne owner.
builder will have the burden of proving that her did not Wild or improve for purpose of
stale.).
0 1.u owner of the propery.am exclusively,contracting with licensed conuacmn in
construct the project(Sec.7044.Business and Profession Cade)The Corrientes L r-
oam taw docs not apply m am an,of property wed Wilds or improvex daemon,no.
who comncu for such pmjecu with a corers carbo licensed putmmmit to the Contracmh
License Law.
0 L em exempt under Sac. B&P C for this moon
Own" Dam
WORKER'S COMPENSATION DECLARATION
I hereby aRbm under penalty of perjury oro of the following declarations:
1 ham and will momm.•CeNfiom ofCc num an self-insure fee WorYer,Compen-
sstion,u provided for by Secdun 3700 of die tabor Code.for Ne performance of the
work for which this Permit is issued.
0 1 have and will maintain Womeri Compensation Imuran.,in required by Section
3700 of the labor Code,for die performance of Ne work for which this permit u toad.
My Workers Cc Pena don Inwnna ori"and Policy number art:
Cam
Policy No.:
• TI 1 TEOF E7 EMPIION FROM WORKERS'
COMPENSATION INSURANCE
(This seeder need Motor cmnplcmd lithe p:rral,Is foram hundred dollen($I00)
or lnsa)
1 certify that in the performance of the,work for which this Permit Is issued,l Nall not
employ any person In any manner an um become subject in dteworkeri Compensation .
Law,of Cottomia Date
Applicant
NOTICE TO APPLICANT:If.aper makint this Cerdfcam of Exemption.you should
become subjc"N Ne Workers Campensadon provision of Nae Labor Code.you muss
OZ roMwidt Comply with such prtwisian or this Permit shot W deemed motes.
z 0 CONSTRUCTION LENDING AGENCY
(.w I hereby affirm that Nem 1,a construction lending.pracy for the performance of
f3i
the work far which this permit is ssued(Sec.3097,Civ.C.)
a Q Landers None
7 z Lender's Address
U0 I certify that I Mw mad this application and mm No are,above information is
U, F corrin.1 agree m comply with all city and county ommoams and sum law mlNn&m
OU building conwtre0an.and hereby authades MPMMn1ives of this city m enter upon do
U above-mentioned property for inspection purposes.
(We)agree to save,indemnify and keep harmless the City of Cupertino against
i..i y Iludlida.judgments,costs and expenses which may in my way ocmc againomid City
U in consequence of the¬ing of this permit.
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT Issued by: Date
SOURCE REGUINS.
r---� 41 Re-roofs
Signatumof ApplimI ofin"t" Dam
HAZARDOUS MATERIALS DISCLOSURE Type of Roof
Will the applicant or future Wilding Occupant om or handle hem duus mamdal
u dented by the Cupenino Municipal Code.Chapter 9.12,and the Health and Safety
AMIWOEIC.Sccdon 15533(.)7 All roofs shall be inspected prior to any roofing material being installed.
❑Yeses
WSun the applicant ar Comm Wilmot aecnp.nt use equipment"devices winch If a roof is installed without first obtaining an inspection,I agree to remove
ith. "air conmmhunu Al defined by On Bay Am Air Quality Management all new materials for inspection.
Diurio?
OYus u
1 haw mad the hauNo ismatedtbmqulmmem,und"chapord.95 of the Celifor,
ria Health tit SafetyCo1c,Sections 25505,35533 J 25534.Iundemund No if the building
J.not currently haw a Wood,that it u my� Ponliblity te ratify the occupant of the
mquimmciaswhichm Wmmp w aoraccmfnmaracapaney. Signature of Applicant Date
ti. 3p—G
ownor or aathoduda ant Data All roof coverings to be Class "B"or better