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COPY OF CUPERTINO
��C"UN1tA.'C;))1�.I1't7xti�IA.k11.,.'-i.
BUILDING DIVISION PERMIT
BUILDING ADDRESS:
11111N'04020042
ERMITNOOi02(]042
OWNER's NAME:
PRANK RTT.T;AQ
PERMIT ISSUE DATE
112,12
NE:
SANITARYD. CONTROL NO.
ARCHITECT/ENGINEER:
BUILDING PERMIT INFO
BLDGELECT PLUMB MECH
=t e I�
LICENSED CONTRACTOR'S DECLARATION
Job DescriptionC
Mal 1em0cea Chapter 9(commencingi
I Mn7
C
Ba.provisionsof
with Saorce 1000) of Division 3 of dsc Buairmn and Rofcasiov Code.and my Incense is
)of
INALEF0
inlforce
CI and caem. Lie.a
DEMO --REMOVE INTERIOR STAIR
MAR 1 8 2004
Dm_ Contractor
7'SDECL
ARCHITECTS DECLARATION
1 understand my plans Shall M used as public reeaNs
Licensed Professional
OWNER -BUILDER DECLARATION
BUILDING
I hereby ef0rm Net 1 am1. exempt froms Ne CantranCod License Lew for IM
following rtaaoa 7 an item Code: Any tiny or manly
Business endow.
do
permit re ennswcC 91mn Improve, deermitt or mash any structure
which requires Permit t construct.
n the applicantn;of rot such permit m files signed statement
pair m its issuance, also pursuant (Chapter 9
pursuant 7000)
thmMiacing
Sq. Ft. Floor Area _
Valuators
it of Business and Code) or
(commencing with Section ]000) of Division 3
tof he al on. Any
Net he is exempt therefrom and U0) bum for 00) alleged exemption. Any violation of
3 I rd)CTD O
Occupancy Type
Section 7031.5 by any applicant for a permit subjects the applicant o a civil penally of
not marc then It. hundred dollen ($Sao).
0 1, as owner of me property, or my employees with wages az Weir sole compensation,
- Required Inspections
will do Mework-and the uncture is not muniedoralferW humid (Sec. 7044, Business
and Professions Code: The Co ermur's License Law does not apply he an owner of
q p
propeny who bui Ids or im proves Were en, end who does such work himself or through his
own employees, provided Wal such improvements sure notln orded ora@red forsake. if,
however, me building or improvement is sold within one year of mmplcuon. We owner.
builds' will ban the burden of proving that he did not build or improve for purpose of
nleJ.
25 as owner of me property, am exclusively contowi ng with licensed canlrucoo m
coastme pmjecl (Sec. 7044. Business and Professions Code:) The Contractor Li -
cam law does not apply to an owner of property who Milds or improvesmemon, and.
contracts for such projects with a conlracmr(s) licensed pursuant m the Contractor's
nce Law.
wxemt mder Sec. B&PC for this meson
I�- � jg�.� Date 2WORKERS
;don,
COMPENSATION DECLARATION
I hereby aRrm under penalty of perjury one of the following decl/.thms:
have and will maintain a Certificate ofConsem m self -insure for WorkefnCompen-
as provided for by Section 37M of me labor Code, for me performance of the
work for which this permit is issued.
❑ 1 have and will maintain Worker's Compensation Insurance. as required by Section
37M of the Labor Code, for the performance of the work for which this permit is issued.
My Workers Compensation Insurance carrier and Policy number am:
Carries Policy No.: _
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
iThis.sectim need nut In completed if the pormit is home hundred dollen ($100)
or lass.)
1 certify that in the per(Momm of the work for which this permit is issued, l shall not
employ any person in my manner an az to become subject to the Workers' Compensation
Laws of Calif oris. Dam
Applicant
NOTICE TO APPLICANT: If, after making this Cenificam of Exemption, you should
become subject to me Worker's Compensation provisions of me labor Code. you must
forthwith comply withsuch provisions or this permit shall M deemed revoked
CONSTRUCTION LENDING AGENCY
I hereby arms that mere is&construction lending agency let the perfmarmm.1'
"
Me work rut which this permit is issued (Sec. 3097, CiN, C.)
Lender's Name
Lender's Address
1 certify that 1 have mad this application and sum than the above information is
correct. 1 agree to comply with all city and county ardmances and state laws relating to
building convection, and hereby authorix representatives of this city he enter upon me
above-mentioned property for impaction purpoms.
(We) agree to an, indemnify and keep harmless the City of Cupertino against
liabilities, judgments, casts and expenses which may In any way secure against said City
in consequence of the Reading of this Permit.
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON -POINT
Issued by: Dat
sC
'ZR l j
'C' A... - f I - '64
Re -roofs
Type Of Roof
Siptuurle of AppinanUContraclor eta
HAZARDOUS MATERIALS DISCLOSURE.
Will me applicant or future building occupant store or handle arrodous material
az defined by the Cupertino Municipal Cade. Chapter 9.12. and 00) Health and Safety
Smooth 25532(&)?
❑Yin [�Ju
All roofs shall be inspected prior to any roofing material being installed.
0'"tric'?
If a roof is installed without first obtaining an inspection, I agree to remove
Will me applicant or 'severe building rampant use equipment or devices which
avardus air contaminants as dcfimd by me Bay Arta Air Quality Management
all new materials for inspection.
❑Yea XN.
I have mad the ha miews materiels requirements under Chapter S95 of me Cxlifor.
nice Health& SafelyCode, Seed. 25505,25533 and 25534.1 understand this if me Wilding
dors not currmlly be. a too.m. mat it u my sespomibilily m noul'y the oceupmt of me
which muatMmet 'rte issumcc at a Cam'cam of Occupancy
�z.
�-rorauthoriradagenl
Signature Of Applicant Date
-1 •o
All roof coverings to be Class "B" or better
I
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