04060193 CITY OF CUPERTINO """' T• � '^ ^
BUILDING DIVISION PERMIT :.'.,CONTrRACTUR INFORMATI'gNNN
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BUILDING ADDRESS: PERMIT NO.04060193 4060193
OWNER'S NAME: PERMIT ISSUE DATE
TO
E SANITARY N 0AOL NO.
IF
ARCHI7DECT/E14GINEER: BUILDING PERMITINFO
BLDG ELECT PLUMB MECH
+�o o LICENSED CONTRACTOR'S DECLARATION
M1 hereby affirm That I am licensed under previsions of Chapt r 9(commencing Job Description
with EccdonIM)of Division 3 of the Business and Proressius Code,and my license is
infall force md.ltea
Lk.nse Chess ADD 900 SQ.FT. (410 SQ. FT. FAMILY RM & KITCHEN,
j 3
Date-Lm.N Committee 490 SQ. FT. GARAGE)
ARCHrrECPS DECLARATION
I understand my plans shall he used u public nand
3w
Std Liccned Professional
Oat I A.AUILDER DECLARATION
a F I hemhy elTmn Nat 11. exempt from Ne Casinal oar License Law for the
po following woaPermit uscos3,Business and Professional Code:Any city or moony
$ which requires•permit m conwuct,alar,imPmve,demolish,or erepairsig ed nncmre
H�> Priormiucermcd e,aluo.ii.res Ue forsuch Cont rmitmfdcavigmedsuumenl p
a (commielkeu with
Scaeu70th)Prob,WAA 3 dtheBminesfand Prolaw(ChaPer 9 Sq.Ft.Floor Area Vah`1i99462
FCS tham he
ial convert
Secfrom and DlvWonro(thceged exemption.
andon.Mynw Cade)or Y
3$
that he LL aempt Nem(nm and Ute buss fm the alleged eumptian.AnY violation of '
Section 7031.5 by any applicant fees permit Subjects the applicant to a civil penalty of APN Number �-
Occupancy Type
notmae than five Insured .
❑I,umrcthproperty,
army..peeawirewageruNei(win co36617094 . 00 2UU5
dthewarlsandStinumtsctotimmndedoffendforWe(Ser.to".Busircset
And Professional Cade:The ContractorsrsLicense law docs ret apply to As owner
of
propeny w ho Wilds or improves Uerton.sM who does ouch wank himself or thou•-h his BKDtNG
awn employ..provided that such improveneau art an,Intended ca offered for".If,
however,the building or
u improvement sold within one year of completion,the sweet.
builder will haw ft burden of proving Out h.did ma build or Improve for Purpose of
ole.).
M 1,As mvrcr of the property am aelusiwly emincting with licensed contecoa in
construct Ue project(Sec.7044.Business and Profesalam Code:)The Cmuscmrs Li. -
me law dors not apply m an owrcr of property who builds or improves Unman.and,
who contracts for such project with a contr war(S)licensed punwnt to the Cmuactars
Lincoln Law.
01un.AeAs .under Sec. .B A PP CC for We noon
O rc
WORKERIC MPINSATI ECLARNIfON
1 herby affirm under penalty of perjury arc of the following cieclantiome
bow end will mainWn a Centifamaf CAMent m self-insure for Workers Compem
cation,u provided far by Sadao 3700 of the labor Cade,for the Performance of the
work for which this permit Is issued.
❑I haw and will maintain Worker's Compensation Insurance,u mquimd by Section
3700 of Ne labor Code,far the performance of Ne work rorwhich Nu Permit is Issued.
My Worker.Compeautim Inunnce artier end Polity number art:
Caller. Polity No.:
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
rntEsectim band ret becompleted If the Permh Is foraba hundred dollars(SIM)
or mss)
I amity that in rhe performance or the work for which this permit is issmd.I shall not
employ any person In any merman ss m become subject to Ue Workers'Compensation
Laws of California.Data
Applicant
NOTICE TO APPLICANT:If.after making this certificate of EmAnNion,you should
become subject in the Workers Compensation provisions of the labor Code,you mut
wJO forthwith comply with such provisions er this Permit Nall be deemed revoked.
Z� CONSTRUCTION LENDING AGENCY
[-r I bemby afrum that then Is a construction lending gency lot the performance of
lY
the,with fur which this Permit is island(Sec.3099,Civ.C.)
�W Q Lamice,Nan.
=1 Z Landers Address ---'
U Q 1 certify Nat I low mad this application and rune Nu the Above Information u
coma.l agree to comply with all city and county on inamea and stat lawn misting In
rU^ building construction,and hereby authatlm mponamadwa of this city to enter up"the
til show-mention PMPCnY run inspection PWPaes
Dv (We)agree in ave,indemnify and keep harmless the City of Cupertino against
fn Ihb11hicajudgmenl,core and expenses which may in anyway acme agalut Wd City
O 7 in cmtw)wmof the granting of this permit.
F7 APPLICANTe UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT Issued by: Date
SOURC REGULA O
? Re-roofs
igna nofAppBcmuContrmmr Data
HAZARDOUS MATERIALS DISCLOSURE Type of Roof
Will the applicant or future building occupant some or handle hassel material
s ill by the Cupertino Municipal Code,Chapter 9.12,and the Health and Safety
er,Serum 25532(a)9 All roofs shall be inspected prior to any roofing material being installed.
❑Yea ®Na
Will the applicant or future building occupant use equipment or devices which If a roof is installed without first obtaining an inspection,I agree to remove
I huardmus sir cWtsmircms a dcObad by the Bay Ane Air Quality Management all new materials for inspection.
oule 7
❑Yea 0No
IhavemW the Mnousmawdalsmquinmcntundcr Chaper6.95ofthe Califon
ria Health h Safely Code,Schou x5505.25533 and x5534.1 undcrsund thul0hc building
does ret currently haw a arms,that it u my ramowibility,m notify the aaowl or the
rcyuirtm nswmc mut a(minnmm ora CenfOaeor Occupancy Signature of Applicant Date
All roof coverings to be Class "B"or better
Owner tar au ri Oagent ate