05030096CITY OF CUPERTINO
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BUILDING DIVISION PERMIT
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BUILDING ADDRESS:
PERMIT NDO 5 03 0 0 96
ER'S NAME:
MENLO R01TTTTR.R
PERMIT ISSUE DATE
12
ONE:
SANITARY CONTROL N0.
CHMIC T/ENGINEER:
BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
j LICENSED CONTRACTOR'S DECLARATION
Job Description
oP
iaof Chapter 9 (commencing
1 Wream by aalrm Net I licensed under ptovisu
i with Sec0an 10110) of Division 3 of the Busimees and Profeslom Code. and my licenseb
; in and affect.
30-DAY TEMP PERMIT (EXPIR. 04/03/05)
LlemseaCCas.Lk.g
DaCommuter
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ORIG. #040P0240 (PLAN CHK ONLY)
ARCHITECTS DECLARATION-....,.,,
I understand my shall W used an records
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plans public
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• Licensed! PNfCillanel
S OWNER-BUILDER DECLARATION
• I hereby affirm that I at eumpl from the Conn ctor's License Law for the
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following reran. (Section RD 1.5, Business and Professions Code: Any city or county
which requires a Permit to conswct, alar, improve, demolish, or repair any mature
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e prior to its issuance. also requires sWappliant fmsuch permit to file a signed summers
that he is licensed pummmW the provisions of the Contractor's lhxme Law (Chapter 9
Sq. Ft. Floor'Area L. y
Valuation $0
a(commencing with Section 7") of Division 3 arrive Budneuand Profusion Code)m
Net he u mumps thersafront std she baro for the alleged esereption. My violation of
-OccupaTic'y
APN Number
Type '
section 7011.5 by mi, applicun for a Permit mbjecn the applium to a civil Nulty of
net mos Nan five hundred dollar (5300).
31620084.00
0 Lastrancrortheproperry,orroyarploym.to w a nthetrmleeampemadon.
Required Inspections
will dh de work and Nestructort u mtinmededoranemd foa.k(Sec.IOH, Budneu
and Pmreslom Cade: The Character, L%aise Law dam not appy in an owner Of
property who Wildsorimpro sshe"md whodoes swhaxishimulfor through his
own employees, provided Nat such ins rovemenu art ml intended moRemd for sak if,
however, the Wilding or improvement is mid within ons year of completion, me owner-
Wilder will have tins burden of proving that du did at build or Improve fon purpose of
sok.).
Gr'. u owner of she property. am emlusively summering with licensed convecmn to
Temporary permit
construct Be project (Sec. 7044, Business and Profession Cade:) Thr uh U-Cmmto•
cause taw docs not appy so an owner of property who Wilda or improm thereon. red,
who consucu for such projects with a eonmecmr(s) licensed purmart m the conuutors
Lie,. Law.
Issued prior to plan check completion
❑ i am esempt untlt Sec.. B A P C rte Nu won
Contractor and/or Owner acceptcompleb9
Dam
WORKERS COMPENSATION DECLARATION
responsibility for correcting addit►ions,
Ihereby affirm under Faulty of perjury arc of the following detamtions:
omissions and revisions on
hae ad will matnwn. CeruEate of Cement to sett-Imam, for Whomes Camper-
n, u provided for by Section 3100 of the Tabor Cade. for the polormemre of tie
completed Blue Prints.
k for which this permit is issued.
Permit good for (30) thirty days
❑ 1 have and will maintain Worker's Computation Insurance, u required by Section
f
3100 of the tabor Cade, (m we peRmmance of tie woo for whish Nis permit u based.
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My Worker's Compensation Insurance artier and Policy number art:
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From
Carrier. Poliry No.:
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
signature
rThuseetion need nolbccompleted true permit Is forme hundred dollar ($1013)
sur kis)
I certify that in the performance of tM work for which this permit is Issued, l adult nuo
Date.
employ any person may manocr m u to hator. subject to the Wmkem' Campenudhn
Laws of CaffoMs Dam
Applic.ns
NOTICE TO APPLICANT: If, After making this CcniEate of Exemption, you should
became objet m me Weraer's Compensation provisions of the later Code, you most
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r forthwith comply with such provisions or this permit ahall le domed revoked.
CONsrRUCfION LENDING AGENCY
1 busby affirm that them u • com rbann lending agency lar the performance of
do work for which this permit is laved (Sec. 309'1, Civ, C.)
Lender's Name
,
y Undue Add.
this suthe aW ve infmmnkn is
unify Nn 1 have read Nuandm Nn
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coma I agree to comply with all city and county ordinmm and seem taws misting to
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y construction. end hereby mthodrt representatives of Nu city m enter upon the
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ago
atunw-e
.Wve-mentionedproperty farinspection
tincdr
unnify npugtoses
(We) agree Is costs Indemnify and keep harmless the Clay of Cup,must id City
0 Ilebilislos,jWgmcnu,costs and<epemoswhich may in any way ectm.gelnss aid ally
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in consequence of the gumming of this Permit.
" APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT
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Issued by: Date
SOURCE REGULATIONS,
Re-roofs
Type of Roof
Signature of Applsc.MConracmr Dem
HAZARDOUS MATERIALS DISCLOSURE
WIII the applicant or future Wilding mxupanutos or handle h rardous m.cdal
as defined by the Cupmuro Municipal Code, Chapter 9.17, and the Health and Safety
diffiec. seatien 2ss3zU>7
All roofs shall be inspected prior to any roofing material being installed.
❑ Ye. ❑ Na
If a roof is installed without first obtaining an inspection, I agree to remove
Will Ne applicant or future Wilding occupant use equipment or devices which
Is duardous air conumtmms u defum0 by the Bay Area Air Cathy Management
all new materials for inspection.
Irinl
❑Yes ONO
I have mW Nmrequirement the haas materiels requiremeunder Chapter 6.95 of the Califor.
1GwmrorsulWri
tie Hear"Safmy,Code, Sections 35305.73533 and 25534.1 adentunde W
d that if ilding
'
docs not currently have a mum, Nal It u my responsibility to notify the occupant of the
requiramcnu which must be met prior to lissome of a Certiticare of occupancy.
Signature of Applicant Date
All roof coverings to be Class "B" or better
Agent Dam