04090083CITY OF CUPERTINO
,..e/�*�'� ♦ r
-r
- BUILDING DIVISION PERMIT
° `Q3'1�1�CTyQtZ��RMR�T�TJ�
yv
BUILDING ADDRESS:
9WY
PE ""04090083
ER'S NAME.-
PERM19TISUEDATE
ONE:
SANITARY C OL NO.
ARCHIIECUFNGINEER:
BUILDING PERMIT INFO
BLDG� ELECTO PLUMB MFCHO
LICENSED CONfRACIDWS DECLARATION
Jab Description
1 hartby affirm tut 1 w limned under provisions, of Chapter 9 Mosmaneng
with Station TOM) ofDiviA.A 3 ofIht Base. and Prole Won Code. and my license is
Limma.Cassgd eRm., Ue.A
ADD 228 SQ.FT. (1 BEDROOM)
Dam Camracmr
ARCHITECTS DECLARATION
I Ma aged my plana WWI he used As public records
,vim
Licensed Professional
OWNE&BUnDER DECLARATION
p
1 hereby a(Srm n I em exempt from the Conincmee Law for the
s: Any c
musur (Sudan and Professional aion Cade: Any city or aunty
following mason.ermitcaness.
®/®J
FA
which requlrea • permit m umatruct, alter hnprow. demote, or mpalr any euucwm
t. gus.
g_�qQQQ
prim islimuenm,almnquimstimisiamofor Con=m)tmfimAsigne(aummant
thommenccensad rothe thou Conuacmfa Lhxnselaw(Chapttt9
Sq. Ft. Floor Area p� ala non
mSudan Divisionf
Section theegBusiness and Poren Cods) or
(commencingwith of
and On basis p3 of
vi
Nat u u exempt therefrom and Ouse bassi fm On allege exemption. Any violation of'
.
?
Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of
3 691;9�91!0 043AY'V14 Occupancy Type
not more than five hundred dollars (SM.
❑ I.uw or my employ= with wags as their mm compensNog,
o=of the property,
will do the work end thematme is am intended or offered for Age(Sce: 7044, Bmirmn
Required Ins '
e a to
and Profession, Code: The Consomme, License Law dos not apply m in owner of
q p
property who bu II ds m improves thereon, end who does such work himself or through his
own employ=, provided that such improvemmu art not intended ora@red for sale. If.
however. the building or improvement usold within ane year of compleon. the oweer-
builder. unit have tion burden of moving ds,t he did nm build or Improve for Purpose of
sale.).
XI1. ex owner of the property, Am exclusively conumting with Rumored mnsoacton to
tum the pmjem (See. 7044, Business and Profession Code:) The Contractor's Li.
come Law date not apply m an owner of property who builds or improve thamem, and,
who contracts fm such projects with a monasterial livened puresnt in to Corm amoes
License Law.
❑ 1 exempt under Sm. B Is P C for this reason
\
WORKERTtWPIFEN'SATION DECLARAT N
1 berehy affirm under penslry, of Perjury oto of the following dMwion:
1 ban and will maintain a CeWTsuste of Consent to self -insure for Worker's Cumpcn-
setlan, as provided for by Section 3700 of the labor Code. for the performance of the
.it for which this permit I. issued.
❑ 1 haw and will maintain Wohmr's Compensation insunnm. u required by SeNon
3700 of the labourCode, far the pmfarmance of the work (.,which this permit I. iamd.
My Workees Compensation bunnm canitr and Policy number tie:
Cartier. Policy No,:
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
Tatou sondem must nonhecompleted lithe permit iaforaee hundred dollen (5100)
nr maF)
I codify that In the performance of the work for which this Permit is iaucd, I shall not
employ any person In any mannersn As m become subject to the Workeri Compensation
Laws of Califomia. Data
Applmam
NOTICE TO APPUCANT. If, after making this Certificate of Exemption, you should
become abject in On Workers Compensation provisions of the halm Code. you must
forthwith comply with such provisions or this permit shall W deemed moked.
CONSTRUCTION LENDING AGENCY
1 hereby Niro Out tbert Ian mMmctinm tending Agency for Om pertarmenm of
tht work for which this permit Is gave (Sec. 3097, Civ. C.)
Lundeen Name
Lundeen Add=
I cattily that 1 haw read this Application and sum that the above information u
cortett 1 agree to comply with all city and county on imumes am Tum laws relating to
building mnsuuction. and hereby aonhorim repremnlmivea of this city W Win, upon f
alww-mentione0 property for inspection purposes
(We) Agree to Ann, indemnify and keep hurl= the City of Cupertino against
j Ilabllitlea,judgments. emu and expenses which may in any way seem against mid City
1'
in conequenec of the gmnting of this permit.
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON -POINT
Issued by:9 Dat
SOU E REGULATIONS. ` pd
�� V
of RoofWIII
Re -roofs (lbei/ng
gnaturt o(Applic HAZARDOUS MATERIALS DISCLOSYIRE tractor DauType
tion applicant or future building accuptimstare orna,define
by 0m Cupertino Municipal Cade. Chapter 9.12. and the Health and Safety
Section 25532(-)?
roofs shall be inspected prior to any roofing mates installed.
❑ Yet / �g�l�q�All
If a roof is installed without first obtaining an inspection, I agree to remove
WIR the applicant or future building occupant use equllooWL in devices which
mit luminous air contaminants As defined by the Bay Area Air Quality Management
all new materials for inspection.
District? l
❑Ys KN.
1 haw me the usardou, materials topommenu under Chapter 6.95 or the Califor,
nia Health h SafclyCode, Sections 25505.25533 and 25534.1 understand din ifthe building
does not currently ban a mnam, Out it is my reapanihility in godly the occupant of dte
rcquim whichmastbe mnpda xamoracarilkamorce q.
Signature of Applicant Date
L� C LaiV
All roof coverings to be Class "B" or better
Ow ur authorized agent Dam