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CTTY OF CUPERTINO�''�'31t�'"�°
INF
BUILDING DIVISION PERMIT
�kCONTRAXICTUR , �Aa1�IMR
BUILDING ADDRESS: n14,; qTAM7nRn or71/
/
PATRICK LAW
PEEMT "b3120034
WS NAME:
PERMIT ISSUE DATE
TRICK LAW
E:
SANITARY OL NO,
ARCHOTCffENGINEER:
BUILDING PERMIT INFO
BILDO ELECTPUME MECH
IS I� ly 0
LICENSED CONTRACTOR'S DECLARATION
Job Description
1 numby anion tel l am licensed under provisions of Chapter 9 (commencing
with Shodon 7000) O(Divi.m. 3a1'Ihe Bumneuend Prefsatwns Code, and my license is
Infell calm
BATHROOM REMODEL (2)' - -
eClussnd
LkeueClsas l.k.N
Dme Convecmr
ARCHITECTS DECLARATION
I undenund my phu shall he used as public ward,
Lianad Pnsfessional
OWNER -BUILDER DECLARATION
I krthy e(firm License: law for tk
11. exempt from WC Contractors
nyc
Cade: Any city
samoso
following meson. Termites IID Business and u
on
f 1'4f
or repair swclure
m Improve, de i structure
which tryuima Permit re cnuwc4 alms,
lawn demolish,
f .
nt I ed
psiorwiu issuance. Nurcqulmatbe applicant launch permiva Blc aalgndstatement
n
rJuuclaw(Cnapmr9
Sq. Ft. FIG'S,=res Valuation
,
purwantwtkpmvislouorofMeBuriness;
(corms ingwith and Pr Cade) at
and
that he.amemttheefromon
Any
that k b "•^rept therefrom and Ne bub for de alleged exemgias AnY Woutlon of
� basis frnftbeeged
///
Section 7031.5 by wry Indium for a permit anbjecu the applicant to a civil penally of
APN- D
not more Ian nvc hundred dollen ($500).
❑ 1, as awes of the property, a my employees with "gas as thehanle compensation.
willdo Mework and Ne WuctureumtlnbMW aaOctW farsab(Sa.70N, BudmsrRe
() s
wired -In a on '
sed Profession Cade: The Cmvecwh License law does not apply w an owner of
q
property who Wilds orimprows thereon. and wadocsaachwakhinewirathrough his
awn employees. provided that men improvements are not inunded m oRemd for sale. IL
however, the Wilding or Improvement is sold within one You of oomplellon. Ne amer-
builder will ave to Wrden of proving Nat he did not Wild or Impmw for pro= of
sabJ.
❑ 1. as owner of the property, am exclusively convening with licensed annecmn In
comuct the project (Sec. 7044. Business and Format Cade:) The ComncwYs Li•
e rte law dors not apply an an owner of prepeny, who Wilds or improves Mercer, ad,
who arvects for such projects with a contrxmr(O licensed Pursuant m the Connectors
m law.
nexmpt under3 t. . B k P C fa NI} wawDabORKER'S
COMPENSATION pECURATION
I kmby aRm under PmuRy a(perjuryNe////7fits following declan0am:
aw aMwilowims DtniOub of Co awulf-luum(orwakerlCompen-
IMy
, u provided fm by Section 3700 of the Ia or Code, for tk perfomance a( Ne
for which Nis permit Is Issued.
aw and will mainam Workers Compensation Immune, u required by Section
a(Me lube Code, for Ne pmfomaae of db woh forwhich Mb Permit b issuedarkdte
Compeued. Insurance carrier and Policy number me:
Comm. Policy Na.:
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(Thb andm toad am w complement Irtk permit is faonhundood cuum sire)
or less.)
I cenify Met In Mc rfrmance of the work for which Nle permit is Issued 1 shall not
empioyony person a manner sou t,�amc b'at he Workeri Compcmmkm
Iowa of CJifo ab �R-- �J��
Applin„ ! / y
NOTICE APPLIC NT: If, Net muting Nn Cenficam of Exemption, you should
bee un fiat m Ne Worker's Compensation provisions or the labor Code, you must
' forthwith comply with such provision at this Permit mail be deemed rovukcd.
cION LENDING AGENCY
CONSTRUCTION
at theed(Sm. rending ager for ftperfomencc rf
1 herby amrm Nftm u .construction
' Nwork rk far which rob peril it Iwai (tea. 3097. Co. C.)
lenders
Lenders Add.
1 1 certify Nat 1 have wad this applicallm erW scab Nu Ne a1mve Inform Won b
' comtt I agree to comply with all city and county on inancca and some lam relating b
Wilding convection, and hereby auMadm representatives of this city an enter upon the
I aWve-mentioned proPcny for inspection Purposes.
(We) agree to save, indemnify and kap humiesa the City of Cupertino spurst
j liabilities. judgments. coast and expenses which may in my my accra against tend City
in amequnce of the granting of this Permit.
' APPLICANT UNDER AND ND WILL COMPLY WITH ALL NON-PQINi
/
Issued by:9 Date
SOURCE REOU Ida - iU
Re -roofs
Type of Roof
ure of Ap snHAZARDa Dew
HAZARDOUS MATERIALS DISCI-OSURE
WIII aMb hualdommawrial
e.
CgChaptuorem
Bred by dw Cupertino Municipal Code. Chapter 9.@. and dN Health and Safety
eCupentofMuni Municipal
Section 25532(¢)7
i't'icl?
All roofs shall be inspected to any roofing material being installed.
Oyu �No
prior
If a roof is installed without first obtaining an inspection, I agree to remove
Will the applicant or future Wilding occupant ere equipmat or devitn which
tensions air conumioants u dcfind by Me Bay Area Air Quality Management
all new materials for inspection.
1
❑Yes Ci Nu
I have read the husNom muonab requirements under Captor 6.95 of Me Chi for-
nisH.1"SalmyCode,Sa9au]5505,25533 uW2553e. l uncomaoA dust if Ne Wiring
doesnot cumntly haw a brant,Nat it is my m mihility m naify Ik occupant of da
royuirtmcnts which nlWm poorwlauana necmmea arae ytq�8�0j
f
Signature of Applicant Date
All roof coverings to be Class "B" or better
o ar vad ag rot nam