03110113 CITY OF CUPERTINO •M
CONTRACTQRTNFORMA ION
BUILDING DIVISION PERMIT ,��,,,
BUILDING ADDRESS; PERMIT NO
GREATER BAY CONSTRUCTION 03110113
PERMT ISSUE DATE
'ER'S NAME:
GB EST F. 200SANITARY NO. CONTROL NO.
ONE:
408 24 -
BUILDING PERMITINFO
ARCHITECT/ENGINEER: BLDG ELECT PLUMB MECH
LICENSED CONIRACOWS DECLARATION Job Description
IWhereby off m1 Nat 1 am licensed under P.Wons of Chapter 9(commencing
aZt wiNsection 7")of Div1alon3ortho Buuneuand Profeauaro Code.and my ties.is
< nfulIfarmandeffat. SFDWL-ONE STORY LIVING 3390 SQ FT
Z License Class Lic.0
GARAGE 634 SQ FT ,,J
qqq Dem Contrecmr `���,j
ARCHI'IEgutacoDECLARATION
1 understand my plans shall W used as public record, J
O10 //�/
u
Licensed Pnsfbyffio
30 OWNER-BUILDER DECLARATION
a E I herby arrrm that 1 Sm1.,Business
from the Contractors Licence Lew for ibe
OO followingreason. eopilt 703 Busitar,and ma,demolish,
Code:Any city of county
$� which requires a Permit m cnesstmcL alters impmw,dcmolbh,or leper any stmclum Nm
HZi prior be its issuance.else requires the applicant for such permit m6leaaixned ..em Sq.Ft.Floor Area Vay(�t)-c160
O that Mu licensed pursuant to Nu e pravisimof the Contractors l.icenx law(Chapter Y
$ (commencing with Section 70M)of Division or the Butanes,and Profession.Crile)or
Net he Is attempt therefrom and Ne bash for the alleged exmptim.My violation of
Section 7031.5 by My applicant for a Permit aubjeeu the applicant to a civil penalty of APN Number Occupancy Type
not mom than fiw handled dollars($5007: 3 5922074 . 00
1,as owner of Ste laopeny,or my emplayms with wages u theiracte mmPmMdOn.
will do mewaak.nd Me stmcture 1,notioundedi,ixBrw forsale(Sm.7014,Business Required Inspections
and Professions Cade:The Conuacone,License Law does not apply to an Owner of
property who Wilds or i m proves theemn.end who dues sue h work himself car through his
Own employes,p com ed that such improvements are not intended mortared forsak,if,
bowever,the building or improvement is mid within ole year of completion.me owner.
builder will have She burden of proving that he did not build Or improve for puepme Or
sale.).
1,as owner of the pmpeny,am eaeluuvely communing with licensed conaaoron m
construct the project(Sec.7044,Business and Professions Cade:)The Common's U.
cense law dors not apply to an owner of property who builds or impmv banner.and
who convince,for Such pmjects with a contrxtoKs)licensed pursuant x the Conmacioes
Licence Law.
1 eras exempt.dile Se .B k P C or thl reason
er /, Dela Way
KER'3 COMPENSATION DECLARA
�t I hereby aflim under Penalty of Priory One of the folluwl "Ions:
1 have and will for by
a Cion 37M of th.Ub,xlf-Wule for Workeronce of n-
n0on,u provided for by Section 7]00 of me Tabor Code,for me perfarmenue of the
work for which this permit is issued.
❑1 haw and will maintain Workers Compensation Insmanx,M required by Section
3700 of the labor Code,for the performance or the work for which this paled(is issued.
My Workers Compermadon Insurance tamer and Policy number ax:
Cartier: Policy No.:
CERTIFICATE OF EKEMFOON FROM WORKERS'
COMPENSATION INSURANCE
(Thh Section Med nut becompleted Ifflue Permit is foram hundred dollar(SIM)
or less)
1 certify that in the Wrformmea of the work for which this permit is issued,I shall not
employ any person in any mmnerao ss M haeme subject to the Workeri Compematlon
U.Of California.Dam
Applicant
NOTICE TO APPLICANT:If.after making this Certificate of Exemption,you should
become Subject to the Worker's Compenvtion pmviaiom of the Isw Code.you mum
foMwith comply with such Provisions or mi,Permit shall be dmmed rewired.
z.0CONSTRUCTION LENDING AGENCY
F+ I hereby affirm that them i,a construction lending agency for the perfurmma of
ryv 7 Be work for which Nb permit is issued(Sm.3W7,Cin C.7
W a Lenders Name
f1. Lender'.Address
Vp 1 certify that I haw tend this application and state that the above information is
IY cancel.I agree to comply with all city and county ordinances and shite laws relating to
r upon
building c e)afire ion,and hereby authmid a presen least t e this Of to CuPo imi age Be
W shove-mentioned progeny fm hermbr t Purposes
(We)agree to taw,indemnify and keep harmlean the City of Cogent,against
ferry Ilabililin.judgmenW costsmdexpenses which may In any way seethe egelnn mid City
O Z in consequence of the grsnling of this permit. Date
^ APPLICA ND STANDS AND WILL COMPLY WI ALL ON-POINT Issued by:
so ONS `
l Re-roofs
,tux b HAZARDOUS MATERIALS DISCLOSU Dam Type of Roof
Will me applicant car fuwre building Oceupantatore car bean chanrdousmamuu
donned by the Cupertino Municipal Code.Chapter 9.12.and the Health and Safety
IS,section2553x0)+ All roofs shall be inspected prior to any roofing material being installed.
❑Ys No
jwnermauffion
III the applicant or um Wilding mcupom use equipment or ricotta which
If a roof is installed without first obtaining an inspection,I agree[o remove
Nnus air contaminants as defined by the Bay Area Air Quality Management all new materials for inspection.
_sf
YC9
ave mad the WAa smawHalsmquimmenuunder Chspwr6.95orthe Califor.
&Safety CMM,Secums25505,35533md25534.1undershirtthatirthc building
urrently he creme.that it h my morn aihility m notify the Occupant of the
nts which at prior w iasumce or.clic , Occup cy. Signature of Applicant Date
d ase
Data All roof coverings to be Class"B"or better