04040139CITY OF CUPERTINO
BUILDING DIVISION PERMIT
CONTM&CTQRi NI''UXtMA.TIE),+�i:'=
o-
.BUILDING ADDRESS:
C BROOK CONSTRUCTION
PERMIT NG04040139
330 STERN AVE
OWNER'S NAME:
PERMIT ISSUE DATE
BARBARA BERNIE
E:
SANITARY NO. CONTROL NO.
(650)965-8972
ARCHITECDENGINEER:
BUILDING PERMIT INFO
BAN O PLUMB MEOCH
LICENSED CONTRACTOR'S DECLARATION
I hereby M. Nprovisions of 1 am licensed under provisioof Charm, 9 (commencing
Job Description
with Swaim 7") of Division Sof Ne Becomes and Proposal... Code, and my license I.
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mteneCla and crcecl.
License Class Lie.x
DEMO (E) HOUSE - Na� �®
Dau Contractor
ARCHITECPS DECLARATION
-
1 understand my plans shall he used as public records
00A
`jam,yr� X
Licensed Professional
OWNER-BUILDER DECLARATION
I hereby affirm shat I am esmap, from Ne Commutes License Law for the
following mount. (Section 7031.5, Business and Professions Code: Any city or county
which requires a permit to construct, eller, impmw, demMlxh, or repair any mnclure
prior m its issuance. also requires the applicant for such permit o file a signed statement
that he is licensed pursuant o the previsions of the Connectors License Law (Chapter 9
Sq. Ft. Floor Area
Valuation
(commencing with Section 7") of Division 3 of also Business and Professions Cade) or
$10000
Nm at Im m exempt therefroend Ne heals ft the alleged exemption. Any violation of
APN Number
Occupancy Type
Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of
not mom than five hundred dulls. (M).
0 T, as owner ofthe property, or my employees with wages as their sole compensation,
/.).L'1U_5i'UU
Required Inspections
will do rhework, and the structure is not intended oraffered farsam (Sm. 7044,
and Pmfesalons Code: The Conhaztur's License Law docs net apply to an owner of
property whobuilds or impromathemon, and who doessuche workhimself orthrough his
own employees. provided Nu such Impmvemenu are maintained or offered forsme. It,
however, the building Or improvement is sold within one year of completion. the owner
builder will hove the burden of proving that he did not build Or improve for purprue of
k.).
L as owner of the properly, am exclusively contracting with licensed cannawan to
11 cmnstroa the pmjecl (Sec. 7094, Business and Professions Cade:) The Contractor's Li.
cents law does not apply to an owner of property who builds or improves Merton, and
who concis for such projecb with a c'onnactor(s) licensed pursue. to the Committees
License W.
❑tem ex under Sec. . B R P C for did. retro.
0 er J4g(i 6. 3 • o
WORKER'S COMPENSATION DEC"_WON
1 hemby f.m under penalty of perjury ane of the following declarations:
l�-Ifor WarkelsCoupon.
hew and will maintain aCmifieam of Consent m�mum
..... u pmvidetl fa by Section 3700 of the, Labor Code, for the performance of Ne
work for which this permit is buttock
0 1 haw and will maintain Waukee Compensation Insurance, ma required by Section
37W of Ne labor Code, for Ne performance of the work for which this permit is isms d.
My Worker's Compensation Insurance carrier and Policy number are:
Carrier. Policy No.:
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
obis section .eed not he eompletad aide permit I. fore.. hundred mllen (SIM)
or less.)
1 comfy that in the performance of to work for which this permit a issued, l shall not
employ any person in any manner so as to become subject to the Workeri Compensation
Laws of California. Date
Applicant
NOTICE TO APPLICANT: II after making this Cmdricata of Exemption, you should
become subject to Ne Worker's Compensation provisions of me labor Code. you must
forthwith comply with such provisions or this permit shall M deemed raveled.
CONSTRUCTION LENDING AGENCY
I hereby affirm Nam Nem is a construction lending agency for the performance of
the weak for which Nis permit is issued (Sec. 3097. Civ. C.)
Lender's Nara
Lemam'. Address
I certify that I have tend Nis application and sum that the show information is
correct. 1 agree to comply with all city and county ordinances and sum laws relating m
building construction, end hereby authmike mpresenutives of this City to enter upon the
above-mentioned property for inspection purposes.
(We) agme to save, indemnify and keep anomalous the City of Cupcnima against
liabilities, judgments, coats and expenses which may in anyway scene against said City
in consequence of the gunning of this permit.
APPLICANT NDERSTANDS AND WILL COMPLY WITH ALL NON-POINT
Issued by: Date
SOURCEL TIO do
Re-roofs
Type of Roof
Sign ar7rc ofApplireHAZA DO
�)// HAZARDOUS MATERIALS
tsameDISCLOSURE
Will the applicant ar forum building occupant etc of handle
Health anmaterial
u defined by 0m Cupertino Municipal Code, ChooseHealth r 9.12. and the and Safely
Sccdan zss3z(a)7
All roofs shall be inspected to any roofing material being installed.
❑Yes .Will
prior
If a roof is installed without first obtaining an inspection, I agree to remove
the aPPIRrml o future building occupant use equipment or devices which
harardnus air contaminants as defined by the Bay Area Air Quality Management
all new materials for inspection.
tricR❑Ys
1.4aamm
1 hew madNe hvarEous materials requirements under Chapter 6.95 of the CalifonHead
tit SafuyCodc, Sections 25505,25533 and 25536.1 undcnmM Nm if Nc bucking
s not cuncntly haw a inane Natit Is m responsihiliry to notify Ne occupant of the
which mat Wmet Poor oris nfaclemlicama mapancy.
Signature of Applicant Date
3Data
All roof coverings to be Class "B" or better
r or authonved agent