04040013TY OF CUPERTINO
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BUILDING DIVISION PERMIT
COiVTRACTOR IjNNFORMA y
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DING ADDRESS:
qTANFORT) PT
NU -DESIGN MANUFACTURED
PERMIT NO, 04040013
ER7421
'S NAME:
;NE:
PERMIT ISSUE DATE
SAM H
SANITARY O OL NO.
ARCHITECDENGINEER:
BUILDING PERMIT INFO
BLDG ELECTPLUMB MECH
0
LICENSED CONTRACTOR'S DECLARATION
lob Description
P
I hereby arfum that 1 am licensed under provisions of Chapter 9 (commencing
with�qya n 7")of Division 3 of MeO neo and Professions and sions Code, MY license is
Tghe and,efface
nml
Li ,ansCClas
PATIO ENCLOSURE (378 SQ.FT.)
Dem' amiummum 7
ARCHITECTS ECL TION
MAY 2a 2004
i sun nJ my Plma I)yc m . ac mcgftls
R'
BUILDING DING
License) Ifeasionel
frDECLARATION
RATIO
I Oat
CRcmpl fronsan IPrlcuionnnr5 Law for
I Ma asompt
I
I hnam'aM.(Su
ttp gy tl"'J
amsa and :AnyCtyOe
name an 7 I. aov Cade: Any city or munry
a (Sudor
w. d
which mquiru • Permit m conswct. ata. Improve, dcmoli+h, or =par any auucort
Conclude,
which e,
prior m its issuance, also requires Me applicant for such permit o rile a signed statement
(Chapter 9
Sq. Ft. Floor Area
Valu non
e that heialimoditommottothe provisiovnftbeConlncmrs6kenselaw
i(commencing with Section 70(10)af Division J of Me Business and Prommons Code) or
. Mat he is exempt Mnefrom and Me basis for the alleged assumption. Any violation of
wi�T�
3"Pevm1�er00
Occupancy Type
Section 7031.5 by any applicant for a permit objects Me applicant m a civil penally of
nm more Man five hundred dollars ($5(10).
❑ 1. u owner of Me prepmy, m my employ= with wags u Malt anlc mmpenadon,
Required Inspections
will do Me work and theswcume is Ml inserted or offered far .1.(Scc. 7044, Business
and Poessiov Code: The Contractors License Law arcs at apply b an owner of
q P
Popery who builds ser improves deman, and who dao such work himsel f or thmugh his
awn employees, provided that Improvements art not intended oroffernd formic. if.
however, the building or Improvement is old within one year of comple0on, Me owner-
builda will have the burden of poring that he did not build or improve for purpose of
"in .1.
❑ I, as owner of the Property. am exclusively contracting with licensed conuacmn m
'
coronet Me pmjen (Sec. 7W, Bulinus and Profesaav Code:) The Contraemes Li.
rove law d= not apply to an owner of property who Wilda or impmves thereon. sand,
who carrots for such majena with a contractar(a) licensed mamma to Me Culmuldra
License Law.
Iamexemptunder Sec .B&PCfar Misrtawn
er Data
WORKER'S COMPENSATION DECLARATION
I nearby affirm under penalty of perjury ase of Me following declendome
have and will maintain a Canufinm of Consent m self-ivum for Workers Compete
n, an provided for by Section 37M of Me labor Lade, for Me Performance of the
k for which this Permit is issued.
1':!!��RRRIIII
have and will maintain Worker's Compensation Insurance, as required by section
of Me labor Code. for Me Performance of Me work for which this permit is Issued.
Workers Compensation Insurance carrier and Policy number am:
CAIE OFF.XFMPIIONf:ItOMWORKERS'
COMPENSATION INSURANCE
f Gtu se W of land not he completed if the Permit is form hu ndmd dollen (1100)
m IaU
I unify Mal In the frulommunce of the work for which this Permit is issued. I shall not
employ any person in any mancrm as in become subject to the Workers'Compensation
Laws of California. Dam
Applicant
NOTICE TO APPLICANT. If, after making this Cenificam of Exemption, you should
become object to the Workers Compensation provisions of the Labor Cede, you run
v (oMwi0 comply with soh provisions m Nis N miuhsll W domed revoked., -
CONSreit.cONLENDINGAGENCY
"
1 herby that Mert iuco nn agency far the penmmanm of
cfvm
' (See. 7. Cing
he work for which Mie pennil is insured (Sec. )097, Civ. CJ
Lenders Name
Lenders Address
r
1 eerily Mat 1 have mad thin application and state Mn Me alove inform d -a is
coma I agree b comply with al city and county ordinances and sum laws relating m
building nomination, and hemby auModae mprosenmias of this city to Cohn upon the
U abovcmcntioned property for inmution purposes.
(Wc) agree to ave, indemnify and keep hornless Me City of Cupenin0 against
9 IiabilideajutlgmenW costs and expenses which may In any way accrue against aid Cityin
/
LIC nenccof Me UNOERSTANDS Aof IND W Permit. L COMPLY WITH ALL NON -POINT
NDERRe-roofs
Issued by: Date
Type of Roof
NaR OfApp ICNIAZARDO DamHAZARDOUS MATERIALS DISCLOSURE
Willy applicantor(Muni Wildinge.
ante harsrdauamteriacOned
Chanumrtm
by the Cupertino Municipal Calc. Chopart 9.12, end Me Heats and safety
;Wictl
e, Section 25532(07
All roofs shall be inspected prior to any roofing material being installed.
❑Ya uWill
If a roof is installed without first obtaining an inspection, I agree to remove
the applicant or future Wilding Occupant use equipment or devices which
hanrdnus air contamivnts a defined by Me Bay Area Air Quality Management
all new materials for inspection.
❑Yes
1 have mad the heardrms materials requirements under Chapter 6,95 of the Califor-
niaHealth, & Safety Code, Smiov 25505.2553 J 25534. I underemnd Mn ifthe Wilding
J= nos c rely hove a mnanc Nat it is apovihilit m noul'y Ibe Occupant nI Mc
my
myuim wmmhman rpria n ante a n;tcamor m r'
Signature of Applicant Date
f9l--y ' • ' zZ.4�}%%
"' "' ay
All roof coverings to be Class "B" or better
Owd�audb r ltd age — m