04050034CfY OF CUPERTINO- -rir°�,yva;.s
..
BUILDING DIVISION PERMIT
€`C TRACT QRIIN�U1LMA'1'IbN:
- -
BUILDINGADDRESS:
NICE & RIGHT CONSTRUCTION
!6"T"00 4 0 5 0 0 3 4
OWNER'S NAME:
PERMRLSUEDATH
ASTEN
E; �.-.. .. ..
i . -
SANITARY O. - CONTROL NO.
ARCH=/ENGINEER:
BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
LICENSED CONTRACTOR'S DECLARATION
-- JOb Description
CSCTI
1 xreby affirm that l am licensed under prevision of Chapter 9 (Commencing
P
with Sadon 70041) of Division J of de 0utlneu aM Pafeuions Cade. and my license u
�K c.Chai,"deGeCL Lm_a
1 -STORY SFD (1955 SQ.FT. LIVING SPACE)
Dam Conuaewr
BASEMENT 1525 SQ.FT. GARAGE 427 SQ.FT.
ARCHITECTS DECLARATION
I understand my plena shall x used u public emends
Licensed Professional
OWNER -BUILDER DECLARATION
1 hereby amens n I am exempt from U Conbamfe License Law for the
fallowingrtssan. o 7rn L5, Business and r iuu Collo: Any oily
''///./✓1C//JP.^
saunty
Improve, de
ms a permit re cnrevucL elms impmsu
which Permit t. or mash ed
-- -- ---
its i such ummum
os permit a filec uignW Ch&pmr t
m its cans ece, ala require; the applicant the Cosmos's
that GOOu
Natmecngwit pSudnt 70013:
anditlasko(Chaptet9
SQ. Ft. Floor Area
Va l$ 000'
of Diviomofthe
Burmese and vi Cade) or
with gallon 7 of Division 3 Ines
Y
dof m al on. Any
Nat x u exempt tbert(rem and Ue buts for Ile alleged earmp0on Any violation of
tham a is exe and
APN Number
Occupancy Type
Section 7031.3 by any applicant for a permit subjects the applicant to a civil penahy, of
not mom than five hundred doll. (0500).
37514012 .0 0
0 I, u owner of the pmpwy, m my employees with ragesu theirsele.Pcnudon,
e ns
Required Inspections
willdothework and Nesuuclumi3.timm�kd.ofemdfoaalc(Sec. 7W.Busiws
and Precession' Code: The conumtue's Li. law dm at appy In an owner ser
q P
property who buiida ser impoves thesmn. and who does such wart himal f ser through his
ownemployess, provided thrisuch Improvements. amimeeded oroRered recreate. IL
however, the Wilding or improvement is mid within ons year of cnmpledon, me owner-
buedu will have the burden of proving that he did not build a improve for purpose of
able.).
L u owner of the pmpny, un cmuenint with Ikeued consumers;
sLP
U.
c nam the project (Sec. 7010. Guiness and Prafestlou code:) The, Conoasefs V-
Business and
conse Law does not apply a an owner of property who Wilde or improves thoom. ad,
who contracts for such pmjccu with a conuamor(B licensed pursuant to the Conuamots
LicenseLaw.
❑Luemp7 and y. ,B&PCfor this canon
�� S
(� 1000
Dam
J
V4ZKEkSCOMPEN ON DECLARATION
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/L��Tgl'v''ea4
I hereby affirm n r proity, or perjury ou of Nef5lowing declandou:
�Y p�
have and a"maiwinsceAOateofcouenuoeelfX- oureforworker'scompn-
+� 3,3Vr110 y'
u
What t u provided fa by Seclian 3700 of me Labor Code. far the performance of the
week far which this permit is armed. /
0 1 have and will maintain Worker's Compensation Insurm x. ss required by Section
370D of me labor Coca, for the performance of tx work for which this permits issued.
My Workefs Compensation Insurance carrier and Policy number.:
Carrier: Policy No.:
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(This section need not xcempleted it the permit is for one hundred doll. (SIM)
or less.)
I certify dual In the performance or Ne work for which this permit is Issued, l shall not
employ any person in any manner so u to become mbjaue Oe Workeri Comp nsation
lawsof California. Dam
Appilit
NOTICE TO APPLICANT: If, after making this Ocrticote or Exemption, you should
become subject in the Worker's Compensation provisions of Ne Labor Code. you mon
foMwith comply with such provisions or that Permit shall be deemed revoked.
CONSTRUCTION LENDING AGENCY
,
I hereby nrmn Nat Nem is s construction lending agency rat the performance of
me work fp which 01u permit is Issued (Sec. 3097, Civ. C.)
Lendes Nurse
Lenderes Address
I certify Nn I have read this applicmion and sum that the above information is
corral I agree in comply with all city and county eNlunces and sue laws calming to
building cowmetion. and hereby mthorin: representatives of Nis city to enter opera the
shove -mentioned property An Impecdon pub••.
(We) agree to ave, indcmtdfy and kap harmless the City of Cupertino against
liabilities ,judgments, cons and expenses which may In my way acme against said City
In consequence of the grandn0 of this pe it.
APPLICANT IfNOG� UA D AND I COMPLY WITH ALL NON -POINT
Issued byrS4tQ� Date J/
SOURCE REi CCAl SNS.
Re -roofs
Type of Roof
rano AppliesnVCdo ler /� Dam
HA2 IJS MATERI LS-0ISCLOSU$B,
Will Ne applkam r furore buildin6ec upmtmorem handle aaAaus materiai
as derined by the CupeNno Municipal Cade. Chapter 9.13, end the Health and Safety
Code, Section35532(x)?
All roofs shall be inspected prior to any roofing material being installed.
❑Ya VINs
If a roof i$ installed without first obtaining an inspection, I agree IO remove
Will the applicant or future building Occupant use equipment or devices; which
7 hazardous air communicate, ss defined by One Bay Area Air Quality Management
all new materials for inspection.
arid?
0Yes XNO
1 have mad the hazarmee mamAis requimmenu under Chapter 6.95 of the Califor.
nix Health@SsfetyCade,Satiou2S50 25 1md25531.1undctstsnd dumifthe building
deca not currently haste a ten I 117' mapoulhili7y m no' y Ile eaupmt Or thc
mqui�pmenuw .aux at can camrmIt a rx<mpancy.
Signature of Applicant "'+Date
U
All roof coverings to be Class "B" or better
Owner see smbo ec t omen
— II