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CITY OF CUPERTINO
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BUILDING DIVISION PERMIT
CON$T,01M T'11. ATIUN
.
,
BUILDING ADDRESS:
LOBE CONSTRUCTION
FERMITND'05090210
OWNER'S NAME:
PERMIT ISSUE DATE
IMAGINATION UNLIMITED
2470 S WIN
5
E;
SANITARY NO. CONTROL NO.
(408)371 -3400
ARCHITECT /ENGINEER:
BUILDING PERMIT INFO
BLDG ELECT PLUMBI�
I�
LICENSED CONTRACTOR'S DECLARATION
Job Description
1 hemby afnrm that 1 am licensed under provisions of Chapter 9 (commencing
p
with Section 7") of Division 3 of the Business and Professions Com.and my license is
I. full
$3SIZZ
REVISION - -CHG WINDOWS & OCCP. LOAD
ic.osomcajay
Damnmgl cuummrin�E -(t A •
NO NEW PERMIT ISSUED/ ORIG. #05080070
ARCHITECTS DECLARATION
1 u ximmand my plans shall k used as public Mc nis
Licensed Professional
OWNER-BUILDER DECLARATION
I hereby Affim that I am exempt from the Contractor's License law for the
follnwing moon. (Salon 703 1.5, Business and Professions Code: Any city or county
which enquires a permit As cnnwuct Blur, improve , demolish, or ¢pair any structure
prior hr Its Issuance, also require. dm applicant for such permit 10 file a signed comment
Ft. Floor Area
Valuatioi$ 10 0
that he is lianscd pursuant to the provisions of the Commeaur's lAcrose Law (Chapter 9
Sq.
(commencing with Section 7000) of Division 3 of the Business and Prufenions Code) At
that W A exempt tlu:mfmm and the buis for the alleged exemption. My 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 Nan rive hundred dollars (M]t.
37507003.00
❑ I, u owtms of the property. a mss wploycn wins wage u drub mic eampcwtim,
Required Inspections
will do the work and the structure is not intended or offered for ask (Sec. 7044, Business
and Professions Code: The Contravenes Lkcme law does rot apply At An own" of
q P
property who builds orimpmws thereon. and whoda"such work hinnelfor Waugh his
own employees, provided that such impmwevenu see not Intended weaned f "sale. If.
however. the Wilding or improvement is sold within one year of completion, the Await,
builder will new the burden of proving that W did not build or improve for purpose of
"Ic)
❑ 1. u owner of the property, am exclusively contracting with licensed c ntracton m
construct the prejecl (Sec. 7044. Business and Professions Coca:) The ConmeMar s Li.
mace law does not apply to in owner of Property who Wilds or Improves themon. and
r-
who contacts for such projects with acontractor (0 licensed pursuant m the Conan es
V
Liceve law.
❑ 1 am exempt under Sec. . B & P C for this moon
��Gt
t Dam
WORKERS COMPENSATION DECLARATION
I hereby alarm under penalty of perjury am or the following declanations:
have and will maintain a Cerunam or Consent m self -insure for Worker's Compen-
provided far by Section 3700 of the labor Code. for dm performance of the
let..
for which this permit is issued.
haw and will maintain Worker's Compensation Insurance, u required by Section
or the Labor Cade. far the performance of the work fm which this permit u issue{.
mlwr`sCwn asoion le —mranm sorts" and Policynumber ere:
�"v-� �•613.� -e Policy No.:�I3t%O 2
-
CERTIFICATE OP OPTION FROM WORKERS'
COMPENSATION INSURANCE
(7haseNm teed not k mmplemd lithe permit Is faomhundmd ddlan ($100)
err Mss)
I cenify that in the performance of tk work for which this permit 4 issued, I "I na
employ any person in any meaner an as As bcmmembject to me Worked Compensation
Laws of Califoram. Dam
.
Applicant
NOTICE TO APPLICANT: IL eAct making this Certificate of Exemption, you mould
become subject to the Workers Compensation provisions of the Labor Coda, you muss
forthwith comply with inch provisions or this maniuhalt k deemed worked.
CONSTRUCTION LENDING AGENCY
I kenby AM. that tkrt is a comrutinn lending agency far tite perfmmanm of
the work for which this permit is issued (Sec. 3097, Civ. C.)
'
Under's Name
,
Leader's Addmu
I «nify that 1 haw read this Application and sum that tW aWw infmmuim M
'
COMML 1 Van to comply with all city and county ordinances and state laws misting an
Wilding convection, and hereby authorise mpmsenutives of this city at Amer upon the
above- mentioned Propony for inspemlon Pu PIA&L
(We) agent to UK. indemnify and p hurrnku the City of Caparison against
liabilides,ju nm,ecAm and to ich may In any way a.. Against said City
In con rice a the grants is permit.
APP ANT U D • NDS AND WILL COMPLY WITH ALL NON -POINT
Issued by: Date
5 BREG ONS.
Re -roofs
Type of Roof
netts pplicandcanmmmr D.I.
HAZARDOUS MATERIALS DISCLOSURE
W Il me applicant At forum Wilding occupant now At handle haurdom material
u deBmd by me Cupertino Municipal Cade. Chapter 9.11. and the Health and Safety
coda,Sadann531(07 J
No
All roofs shall be inspected prior to any roofing material being installed.
❑Yes yi
If a roof is installed without first obtaining an inspection, I agree to remove
Win the applicant or fatum Wilding occupant use equipment or devices which
iI haurdous air contaminants u defined by rim Bay AMA Air Quality Management
all new materials for inspection.
Dinrict
❑Yes *U
'
I haw mad the haamdam matedab uRcmenu under Chepmr6.95ofthe Califon-
nieHMILK &Safety 'ore , 3533 and8574.1umleetand datifthe Wilding
don rot cu aw ate t it u my responsibility m mdfy tite occupant of the
mquimmeat bleb pat"mismanmaracwtirmam ofocWpangy�
Signature of Applicant Date
1nDlam
All roof coverings to be Class "B" or better
own ar. rice d.gmt