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CITY OF CUPERTINO
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BUILDING DIVISION PER
BUILDING ADDRESS:
LEISURE LIVING & DESIGN IN
PER MITN .
85030189
71,jS&PTE191BERPERMITISSUEDATE
SANITARY 440. CONTROL NO.
ARCH11ECnEt7GINEER:
BUILDING PERMIT INFO
BLDGELELT PLUMB MECH
(�
LICENSED CONTRACTOR'S DECLARATION'
Job Description
1 hereby affirm that 1 em Bennsed under provisions of Chapter 9 (commencing
with Section 70011) of Division 7 of the Businaund Profs Ione Cnde.eMmylicenuis
in full force and effect. 12
Llcanu Cl Lle.a
PATIO ENCLOSURE (240')
_
Dau onrtacmr
AR H S DECLAR ION
I ts 1 as ma used u sada
LlenuJ Prafu..ion
OWNER -B from Me RATION
I hereby nu law for the
exempt from tie Cssion
(Srm that 11.
o e:A
following eeoln. (Semon 71171.3,BusuessAnd ernm Code: Any city orcounty
Maso . ,
which mqulma ove. deermitt at repair any umem
permit re eenumn, alto, rat
Imve,
n
prior mits mmund p,atmrequlru the applicant the Conpermitmma Law (chapter
thabeHcansW puraam an [be theeBuarer'sIJcenslowna CMpur9
Sq. Ft. Floor Area
Valuation
of Divisionl
(commencing with Section 10M) of Division? the Business andCade) Or
on. Any of
and the aura for the alleged exemption. Any
Net io ts campy the
''6Fq U ,,�w..{{,�
3 V g't!"eO O
Occupancy Type
l penaon
Section 7071.3 any applkw for permit aubJeu the applicant m •dull penalty of
five hundred (a
not mom than five hundred dellen (f500).
O'L•lt
❑ 1,uco ner of the property, or my employees with wage, u Meir sale compensation,
Required Inspections
will do the wait, and Meantime is not intended or offend for sale 7044, Business
And Professions Code: The Cmuano s Licence Lew does not apply to an owner of
q P
property who builds or improveidereon,end who Oatsouchwart himulfor through his
awn employee, provided Nat such Improvements Are not intended oroRerW fm Asia. If.
however, Ne Wilding or improvement iaaold within end you ofcompledm. the owndr-
builder wilt haw the burden of proving Mut he did sat Wild or improve far pugmu of
'
sale).
❑ 1, as owner of the property, em exclusively contracting with licensed contractors to
construct he pollee, (Sec. 7044, Business and Professions Cade:) The Contractors Li-
cense Law Joey not apply to in owner of progeny who Wilds or improve Mercer. sad,
who contracts for such projects with a cdm tm(a) licensed pursuant to me Contractor's
License few.
❑ 1 em exempt under Su. B k P C for this resson
Owner Dau
WORKER'S COMPENSATION DECLARATION
I hereby affum under penalty of perjury ate of the following declarations:
hats and will maintain I CenlOew of Consent I. self -Insure far WoltersCareful.
wind. AS provided for by Sedan 7700 of the Labor Code. for the performance of IM
wort for which this Permit Is issued.
❑ 1 haw and will maintain Workers Compeaation Wunnce, As required by Section
77mof Ne Lobar Code. far the performance of Ne welt for which this permit is issued.
My Worter, Compensation Insurance carrier and Policy number art:/
Ce Mer. t%ai.4 r4�Al Ill Policy No.: ��rF.`/�/
CERTIFICATE OF EXEITPT70N FROM WORKERS'
'
COMPENSATION INSURANCE
(This section need not N completed if,be Permit is farow hundreddnllars (SIM)
or Ica.)
I cer ify that in the performance of Ne wort far which this permit is kandd, I shall not
cmplayanypcsson ire an emb WoheWCompensman
lewaofcslifomie.D
NOTIem
NOTICE 70 APP ft m n em0eate of Exemption, You Arnold
become subject ro the Woh s provisions of the Leber Code, you mu{,
forthwith comply with such previsions or this permluhall N deemed ranked.
CONSTRUCTION LENDING AGENCY
I hereby affirm Net mem B a conation lending agency for the performance of
the wish for which this permit it issued (Sec. 7097. Civ. C.)
Lenders Name
,
Leader's Address
I cenify that I Mw read this pplication and Aute that tie above infarm211n0 is
carrecL 1 ages to comply with all city and county ordlnane,and stow law raining le
Wilding concoction, and hereby amhadn representatives of this city he enter upon the
above-mentioned property for inspection purposes.
42
(We) agree to ave, indemnify and yup Norman the City of Cupertino ageWt
liabilities, Judgments. costs and expense, which may In any wry came against said City
In consequence of the totaling of wit rmiI.
AP LICA UNDERSTANDS WILL CO LY WITH ALL NON -POINT
Issued by: Date
SOURCB ULATIONS.
Re roofs
'Uf
Silo a Appl' VCa t Dam
HAZARDOUS RIALS DISCLOSURE
III
Type of Roof
mail mor future Wilding document nom or handle henrdoea material
u de0ned by the Cupeninn Municipal Code, Chapter 9.13, and ,he Health and Safely
cafe, Section 35573(07
All roofs shall be inspected prior to any roofing material being installed,
03 Yet 0 N
If a roof is installed without first obtaining an inspection, I agree to remove
Will the applicant Nwrebuilding arupantueequipment wdevie, which
t Mverdnus air conuminnus u dcOndd by the Bay Aro All Quality Managcmeal
- all new materials for Inspection.
Inric,7
❑Yus ❑Nu
IhawmWtheheoardwsmmllnamquimmenuunJ rChepkr6.95ofthe Celifor-
ria Hcelth&Safely ,Sadam3330 25577 mJ 35374.1 undcutsnd thulflhe WIIJIng
Jane oar curmnm a mnml, the my reeponelhll y w nntil'y the occupant of coo
rcyuircmcnuw c no,mmatp r ruuane or wof Occupancy.
Signature of Applicant Date
G _PC sow
All roof coverings to be Class "B" or better
Owner 'ed
or who e t nem