05020013�OCZ'1�P�
�<G
yet
m.
ac
ase
ype Z >
i d
O
z
a
ow
J
U
0
U
CITY OF CUPERTINO
>a
r
BUILDING DIVISION PE MIT
JUDY LIN
BUILDING ADDRESS:
PERMITN%5020013
28 STANFORD TEL
R'S NAME:
PERMIT Mind DATE
JUDY LIN
&'11
NE:
SANITARY CONTROL NO.
ARCHITECT/ENGINEER:
BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
LICENSED CONTRACTOR'S DECLARATION
Job Description
1 hereby arrirm Nm 1 an Ilmaned under provisions of Chapter 9 (commencing
with Section ]0110) of Division 3 ofthe Business ad Prorculuu Code, and my license is
in full to. and affect.
ADD 1048' (MS SUITE/GUEST SUITE)
Licenu Cl.s Lk. Y
Dale Can ,mor
REMODEL BATH/ENTRYWAY/LIVING ROOM
ARCHITECI•S DECLARATION
I understand my glom shall W tired as Parise mm�rda
I w B � O p�
'\Y��19(�1\�YL 9r`�
Liccnud Pmfcuioml
OW NEm BUILDER DECLARATION
I hereby .(Sero that 11. exempt from the Contractor's License taw for the
followingMemo.] Business and Code: Any oily lir [aunty
improve, lire awetule
enmlmcL alar, improve,
which leyulroa • Permit rears
e, also to nt for h permit t a sig ed
! push¢aihiuuampal.letothe WapionsoftheCO
V bWo00
Sq. Ft. Floor Area V`V�
outor'aoienseLaw(hmmcm
' thethelslicenudpursunniteNopmvisionaoftheComucor'tLitenulsw(Chapmry
I(commencing with Section700d) of Division 3 of the Business and Professors Code) or
that he Is exempt Ncmf om ad the buds for IN alleged caemptlan. Any violation of
Section 7031.5 by any applicant for a permit subjects the epplical to a civil penalty of
ApN Number eupaney Type
not more than live handled dollars ($500).
.
35932024.00
0 1, u owner of the property, w my empioy. with wag. u their sole compenudon,
Required Inspections
(l p
win do the werk. ad he atectum is or in¢nded or offered for &.as(Sec. 7044, Business
ad Prefe.iam Code: The Comjwbdh Limnse Law data not apply m an owner of
Property who build, or improves theleon.and who doesuchwork Mmtelf o through his
own employees, provided that such improvements are at intended coffered fmsale If.
however, Ne building or Improvement Is mid within one yew ofcomphohm. de coma -
builder will have lie burden of graving that he did not build or improve for Panama of
sale.).
❑ I, . owner of the Mainly, am exclusively canuactiaS with thermalcantrachn u
comtmct the Project (Sec. 7044. Business and Poefessda s Cade:) The odometer's U
corse Law does not apply Wen owner of properly who Wilda or improv. thatch, ad
who contracts far such projects with a caatractor(s) licensed pursuant W the cmumcme.
License law.
❑ 1 am exempt under Sec. . B & P C for this moan
-
Dan
IV r, w
WORKER'S COMPENSATION DECLARATION
Ihereby million under penalty of perjury one of0¢ following declarations:F
O lhaveandwill maintain a CandlemasmofCocnt m self -inure farWarker'sCompen-.don,
u provided for by Scotian 3]00 of cite Labor Code, for the pnnelfoana df Ne
work for which dads permit is Issued.
1 have ad will maintain Worker's Compensation sauna,u required by Section
3700 or the tabsCade, forthe Md... ofhe wok for which this permit is hsead.
My Worksh Compen ,tion Warsaw Cartier W Policy number are:Ca
rl: Policy No.:
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(this section need not he comptard Bthe permit Isforaw hundred infa s (x100)
or lass.)
1 candy that in the performance of the work for which this permit is lumd. I shall not
-
employ any parr in any meaner a u W become subjal to NC Wdrkeri Compensation
Law. of California. Date
i
i
Applicant
NOTICE TO APPLICANT: If. after making this Ccmdimin of Exemption, you should
become subject m the Worker's Compensation provision, of the Lam Code, you muss
Z rorthwith comply with such pmu visioor this Permit Shall W revoked. nked.
CONSTRUCTION LENDING AGENCY
Inaffirm thus Nem iteomlmNmlending agency for Nc performance of
> On work Ter orw which this permit Is issued (se[. 3097. Civ. C.)
Lender's Namc
Lcnder'a Addrrs
z
yI comfy that I have mad this application ad mite Net the above inf.on. too is
carte'. I ague I. comply with all city ad county ordinates and shoe levo relating to
buildingconstruction.rept city Wenter upon dn
J
mam-awnflowd property for inspection panpOWL
1.s.,indemniya d
City
(We) agree to cave, indemnify es keep hay in an the City dCu gamin against
habeas
expenses which may In any way neemmagalnstmid City
'
to consequent ofthegrauing S AND WIL
Z mcanseq N"r of the UNDERSTANDS
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON -POINT
Issued by: Date
SOURCE REGULATIONS.
Re -roofs
Type of Roof
Signal ear AppldcantiCdnwcter Da,
HAZARDOUS MATERIALS DISCLOSURE
Will IN applical or future Wilding occumetstnm or handle havardou mantis]
defined by Inc Cupertino Municipal Code. Chapel 9.13, and the Hcailh ad Safety
ode. Section 35533(a)7
All roofs shall be inspected prior to any roofing material being installed.
OYcs ON.
If a roof is installed without first obtaining an inspection, I agree to remove
Will the applicant or future building Occupant use equipment or dcvleas whim
mir heretical air contaminants u defined by IN Bay Arca All Quality M.agcment
all new materials for inspection.
iuric0
0 y ONo
Imquimment,
I have sad the haurdom materials requirements under Chapter 6.95 of the Califor.
, Sections 35505.35533 ad 35534.1 undcnd that lrthe building
ia Health & Safety Codehr
ocs not currently how: a mmol that it h my mpooinillty W nodfy the occupant of the
'
whim must be met prior m issumcc ora Ccdimate ear Occupacy,
Signature of Applicant Date
All roof coverings to be Class "B" or better
wher ser auNOHved agent Date