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CITY OF CUPERTINO
CONTRACTOR
BUILDING DIVISION PERMIT
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BUIL DING ADDRESS:
C BROOK CONSTRUCTION
PERMIT "°04'030136
1
NER'S NAME:
PERMIT ISSUE DATE /
C/
BARBARA BERM
'51411:SANITARY
NO. CONTROL NO.
(650)965-8972
ARCHITEC rENGINEER:
BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
LICENSED CONTRACT'OR'S DECLARATION
Job Description
1 hereby affirm (hal I am Reamed under previsions of Chapter 9 (commencing
with euvnras erd Profcsslum Code, andmylicena is
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I. ilforcnnd ClenDivialon3afdm
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1 -STORY SFD (2005 SQ.FT. LIV '��Ip-Y/l/�li¢L► 0
LieneCleanderrec''
License Class Contractor.
Data ea01 aamr
GARAGE 400 SQ . FT .
ARCHITECT'S DECLARATION
I accoutered my,haxshall heumdaspublic=am.
DEC 13 Y004
Lkcnscd Professional
OWNER -BUILDER DECLARATION
1 hereby affirm that 1 am exempt from the Connector's License Law for the
following reason. (Sectiun 7031.5, Business and Professions Code: Any city or county
which requbes a permit to Conswct alter, improve, demolish, or repair any structure
prior or its issuance, else requires the applicant for such permit o flea signed statement
Sq. Ft. Floor Area
Valuation
that he is licensed pursuant to the provisions ofthe Contractor's Licenec Law (Chapter 9
(commencing with Section ?000) of Division 3 of the Business and Professions Code) or
$500000
Net he is exempt therefrom and the basis for the alleged exemption. Any violation of
APN Number
Occupancy Type
Section 7031.5 by any applicant for a permit subjects dee applicant in a civil penalty of
not more Then five hundred della. (5500).
❑ I, a owner of the property, or my employeex wide wages so their $ole mmpentation.
Required Inspections
will do the work and the avun an isnot intended or offered for aale (Sec. 7044, Business
and Professions Code: The Cmnlamors Lt. Law dace not apply to an Owner of
property who bu ilds or improves thereon. and who does such work himself or through his
awn employees, provided Nat such improvements are nolinmnded ora@red forale. If,
however, dee building or improvement is sold wimin one year of completion. the owa..
builder will hove On boder of proving deet he did rut build or improve for purpoa or
mic.)
, as owner of the property. am exclusively contracting with licensed comments on
onswct to project (Sec. 7044, Business and Professions Code:) The Contractor's Li.
cents Law does not apply in an owner of property who builds or improves thereon. and.
who contacts for such projects with a contractor(s) licensed pursuant to the Contractor's
License Law.
❑ I ren exerprt'under, Sec.,B& P C far this m�,ofn
/ �s
Da() q l e, N'
WORKER'S �MPENSATION DECLAR7aLON
I hereby aRrm under nahy of perjury enc of Ne .tolIImams Ou laommur
-
I have and will maintain aCeo fica a of Consent to self-insum for Warkers Compen.
sation, an provided for by Section 3700 of the Labor Code. for dee performance of the
work for which this permit is issued.
❑ I have and will maintain Worker's Compensation Insurance, a required by Section
,
3700 of the Lobar Co te. for Nc porformancc of the work for which this permit is isseed.
My Workers Compensation Insurance canine and Policy number am:
Carier,Policy No,:
CERTIFICATE OF EXEMPTION FROM WORKERS'
"
COMPENSATION INSURANCE
Mot section need no(hecomplcmd time Permit is forma, hundred dollars (5100)
Ica.)
1 certify Nat in to performance of the work for which this permit In Issued, I shall not
employ any person in any mmnerm as On become subject o len Workers'' Compensation
Lawn of c.liforni.. Data
Applicant
NOTICE TO APPLICANT: If, after making this Cenificate of Exemption. you should
become subject m the Worker's Compensation previsions of Ne Labor Code, you moat
faMwith comply with such provisions or this permit shall be income! revoked.
CONSTRUCTION LENDING AGENCY
1 Washy aRum Net there is a Construction lending agency for me performance of
the work fur which this permit is issued (Sec. 3097, Civ. C.)
Lender's Name
Lender's Address
I ronify mu I have read this application and stsm that the above information is
correct I agree to comply with all city and county ordinances and smte laws misting to
building convection, and hereby authadm misounu advcs of this city to enter upon the
above-mentioned pmpeny for impaction Purposes
(We) agree m ave, indemnify and keep harmless the City of Cupeni t. against
liabilities, judgments, costs and expenses which may in any way accrue against said City
in his Permit.
TUNDEROf me flooding of t
APPLICANc UNDERSTANDS WILL COMPLY WITH ALL NON -POINT
Issued by: Date
so URC °ULA ONS.
Re -roofs
O
S urcafAppli _ Dare
HtrmrSMATERIALS DISCLOSURE
AZARD_
Type of Roof
Will the applicant or future building Occupant atom or handle harardoes material
as &flood by the Cupertino Municipal Code, Chapter 9. 12, and me Health and Safety
On. Section 25532(a)?
All roofs shall be inspected prior to any roofing material being installed.
Yes o
metre building
If a roof is installed without first obtaining an inspection, I agree -to remove
Will the applicant or Occupant s equipment or devices winch
it hmsdous air contaminants as defined by me Bay Arca Air Quality Management
all new materials for inspection. F`
District?
❑Yes
I have mad me broamous macdals.quimmCms under Chapmr6.95 of the Celifnr-
nix Halm & SafetyCotle, Scction 355[15,35533 wm25534.I understsnd matifine building
,
dans not eur,mlyhaw x mmmNet It u my mspomibiliiy m no ify the wcupam of me
acgiremcrt ichmustbcmmpdmmiss cc or Qcouli foecy.
gnature of Applicant Date
.3
overings to be Class "B" or better:"
All to f cr:
Ownar aulhorizctl agent Dam