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CITY OF CUPERTINO
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PERMIT
CONTRACTOR N. FORMATION :%
BUILDING DIVISION
BUILDING ADDRESS:
PERMIT NO, 06030011
1182 STAFFORD DIRIVE,
OWNER'S NAME:
PERMTT ISSU DATE
VICTOR LU
E:
SANITARY NO. CONTROL NO,
ARCHITECT/ENGINEER:
BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
LICENSED CONTRACTOR'S DECLARATION
lob Description
I hereby affirm that 1 am licensed under provisions of Chapter 9 (commencing
P
wish Section 7") of oiWvon 3Ofshe Susxand Professional Code. and my license is
in fall town, ad elfeet.
214' ADDITION OF LAUNDRY/KITCHEN
License "a IJea
Dow Contractor
611' REMODEL OF KITCHEN/GUEST BATHROOMS/ENTRY H
ARCHITECTDECLARATION
understand my plans shag wed ee d as public runM1la
Licensed Professional
OWNER -BUILDER DECLARATION
I herchy a1Erm Nat I am excmps from the Contrxmrs License Law for the
following mason. (Section 71131.5, Business and Prefesslrns Code: My city of county
which reposes a permit to cnnsuact. agar, imPMW. demolish, or repair any atrudur
prior w its issuance. also requires the applicant for each permit to R4 a signed statement
that W is hectored pursuant o she provisions of the Convectors Linos, law (Chapter 9
Sq. Ft. Floor Area
Val0fibU 4 3 3
(commencing wish Section 7000) of Division 3 of the Business and Professions C
that he u exempt therefrom and she basis for the alleged osculation. Any vi.I='m
APN Number
Occupancy Type
P y yP
Section 7031.5 by airy applicant for a permit subjects she applicant to a civil penalty of
pm th
oat ran hundred Bw hured dollars ISM
37611022.00
❑ i, u owner of she pmpwy, w my employers wish wagei u theumlc compemssdon.
Required Inspections
9 reyip n P
wig do she wars, and theawdpr u net tnundedarofferA kersale(Sce. 701/. Business
The Canuactara License Law dons
and Professtwu Code ret apply m u owner of
fw.mv�
imgnumsdorsals,hu
...employ ,proviimpmwsch icaprarWoods Me
thm tech improwm raaerd for own If.
not inure
aowews.
within ofoo
AMwevv. she building or improvement 4 sold within ter¢ year of cemPletian. the ownery
see Wil ing or i
1(7I7�' (Lt�]
builder will hose the Wusen a(pemobs, that he did wt Wild or improw far purpose of
arM�M1
sale.).
0 1, es Owner of she property, am uclmivcly contracting wish licensed conuacmrs to
the 7064. Business Pro(usioas Cada:) The Conuaemrs U.
;FR All
nsuuct project (Sun. and
Law does Witter improwa derton,
;ynrjF
co... art apply m an owner of property wise of and
who contracts for such pmjecos wish a contraemrts) licensed pursuant to she Conuaemis
nn la" w.
0l1amexempt und'M Sec. . B S P C for is rtuon
L
Dag
�
RFI\t/�yirik,
,
00. 'S COMPENSATION CATIONOwner
fsr
i herb aRism under penalty of perjury ane of the, following declarations:
T him and will maintain a CeNOceta o(C..., m self -insure for WoheesCompcn-
smfon, an provided for by Seetion 37M of the Labor Code, for see performance of she
wars for which this permit is issued.
❑ 1 have and will maintain Wohers Compensation Insurance, as pupated by Section
3700 of the Labor Code, for she perfurmance ofdrt work for which this permit is issued.
'
MY Workers Compereation Wastruner carrier and Policy number ape
CMMr,Policy No.:
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
,
(Tow acctum need not W completed if IW permit b for come hundted Oil. ($100)
r
of lm)
I cenih that in she Performance of she work for which this permit If issued, 1 shall not
pens'
employ any person In NY mmhecpmC ldbjRl m dC Wafker,' Garrlpewillarl
eawaafny
Dal ��/�O
Applicant -/�/•1/
NOTICE TO APPLSCANT: If, after making this Cenificate of Exemption, you should
Income subject to the Worker's Compensation provisions of she Labor Code, you muse
forthwith comply wish each premonitions or this permit shall be dmmed revoked.
CONSTRUCTION LENDING AGENCY
T Wphy alOsm Nat port is a construction lending agency for she performance, of
she work for which this permit is issued (Sec. 3097, Civ, C.)
Lenders Name
Lenders Address
1 certify that I have rad Nis application and sub, tha she aWw lot ..tiuo is
correct. I agree to comply wish all city and county oNinances and state laws relaung to
building cm.,ion, and hotels, Mulamire repoescntatiwa of this city m enter upon the
above-mentioned property for mslocuon purposes.
(We,) agree to vg, indemnify and omp hnmless the City O(CupeNno against
,
liabilides,judgmcnts. cwts and expense which may in any way accrue agdnstseid City
in c.wegnenee of the grating of this permit.
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON -POINT
Issued by: Date 611-13-06
SOURCEA,EGULEON
Re -roofs -
Type Of Roof
Zo c
atumOf ppl',n Cammsaor Dow
HAZARDOUS MATERIALS DISCLOSURE
11 the applicant or future Wilding occupant score or handle harardous material
as dcOned by the Cupertino Municipal Code. Chapter 9.12. and the Health and Safety
Cade. Seeded 25532(.)7
❑Yes op No ,:
All roofs shall be inspected prior to any roofing material being installed.
Will she applicant or future Wilding occupant use equipment or device which
If a roof is installed without first obtaining an inspection, I agree to remove
=�`aadou air conuminanu u dcOned by the Bay Ma Air Quality Managemcm
all new materials for inspection.
D
❑Yes ,7No
I have mal she because. materials teupirmemo under Chapter Q95 of die Califw-
niaHealth&SofctyCodc.Sc =25505.255336 25534.Iun@rsunddutifth Wilding
does not currently haw a cnanL that it u my mapossihility le notify she axup., of the
myuimm.,nu which mostW met prior m issuance ofa Cwufin ter pansy.
-3Z `
Signature of Applicant Date
4Q1 Z icor
All roof coverings to be Class "B" or better
wnc lhori, dagcmt Dam.