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CITY OF CUPERTINO'
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BUILDING DIVISION PERMIT
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BUILDING ADDRESS:
HILLHOUSE CONSTRUCTION
PERMIT NO
05040054
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FERbm ISSUE DATE
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SINrrlRnY Al 2 0 CONT0.0L 10.
ARCHITECT/ENGINEER:
BUILDING PERMIT INFO
BLDG ELECTPLUMB MECH
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LICENSED CONTRACTOR'S DECLARATION
Ib Description
ODSCO
y affirm 1 atm ved under provisions of Chapter 9 (commencing
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wish Suedon 7G'IIR ofMA.lon 3 of Sha Basi^•.. and Professions Code, aod my Iicem is
to see=.lec°Ca:ndeneCL uc.g
REVISION --CHANGE WORK SCOPE
NO NEW PERMIT ISSUED/ ORIG. 405010066
Dam usactar
ARCHITECT'S
1 understand my plans Shall W used As public records
Licensed Professional
OW NER-BUILDER DECLARATION
1 hereby air.. am[ I am exempt from the Contractor's License Law for the
following mason, (Section 7W I.S, Business and Professions Cade: Any city of county
which requires a permit to connect. almr. Improve, demolish. or repair any Structure
prior m its issuance, alto requires the applicant far such permit to rile uigned wmment
that M is licensed pursuant o as pmvislov of the Conuactw's Linow Law (Chapter 9
Sq. Ft. Floor Area
Valuation $0
(commencing with Session 700D) of Division 3 of the Business and Profusions Code) or
that he Is exempt therefrom and the bases fm the alleged exemption. Any violation of
APN Number
Occupancy Type
My AAppolicanan(SSWrmit Subjects the applicant to a civil penalty of
Sccdortaan
mann❑ fin
Lasawnaroftimproperty, army employees with wages astheirwlecompenvumn,
36901028.00
Required Inspections
willdo the work, and SheSwerure 4norinmodedmoRemd fonate(Sa.7014, Busims
and Pmfeselons Code: The Conuacures License Low dads nal apply An an owner of
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property who Wilds At improvestiro eon, end wha doessuch work himsel f m through his
awn employees. Provided that such improvements Am not Intended martered for ASIA. II.
builder, the building verW one you of mproefor the owner-
,f
of proAtIsholdwdiin
builder will haw the burden of proving Nat he did nm build a improve for purpose of
ole,).
❑ 1. as owner of the propeny, am exclusively contracting with licensed contractors an
construct the pmjen (Sec. 7044, Business and Pmfuslav Cade:) The Contractor's U.
came law does not pply to an Owner of properly who Wilde or Improve, thereon, and,
who contracts for such pmjecu with a conuaemr(a) licensed punnet to the Contractor's
License Law.
❑ l4mexemPtandm See. ,Bit PCfAAdWmaon
toner Dau
WORKER'S COMPENSATION DECLARATION
1 hereby affirm under penalty of perjury am of the following declaration:
❑ I haw and will malnuin aCcrtiriate of Comm toself-Ivum fm Worker's Compen.
cation. AS provided for by Sudan 3700 of the Labor Cade. for the performance of the
wmk for which this permit is issued.
❑ 1 haw and will maintain Worker's Compensation Wasnu ce. AS required by Section
3700 of the Labor Cade, for the performance of IN wit for which this Permit is Issued.
My Wok -e4 Campemtion Insurace wrier ad Policy number am:
Carrier. Policy No.:
CERTIFICATE OF EXEMPTION FROM WORKERS'
-
COMPENSATIONINSURANCE
(MIS Means need not W co nplem4 titit permit IS foronchundmd dollars(SIM)
our rasa )
I certify Shot in vee performance of the work for which this Permit is Issued. I shall not
employ any person in any m cherso As to become subject to the Worker! Compcm0an
laws of California. Dam
Applicant -
NOTICE TO APPLICANT: If. after making this Ceninam of Exemption, you should
become subject to me worker's Compensation provisions of the LaWr Code, you mus
'
forthwith comply with Such provisions or this Permit shall be deemed mwked.
CONSTRUCTION LENDING AGENCY
I hereby afilfm that there is a construction lending agency four the performance of
the work for which Ws permit is Wucd (Sec. 3097, Civ. C.)
Lender's Name
Lender's Address
I certify that I haw read this application and tom that the aWve information es
corm I Agra to comply with all city And county ordinances and emir law relating to
building construction, and hereby authods mpraeomiws of this city to enter upon me
above-mentioned property for hall PLOPores
(Wes) Sara to saw, indemnify and kap harmless the City of Cupertino against
liabilities, judgments, costs and expenses which may in anyway acerae against aid City
in mmgmnea of the wanting Of this Permit.
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON -POINT
Issued by: Date
SOURCE REGULATIONS.
Re -roofs
Type Of ROOF
Signature afAppliesAZARDO Dam
HAZARDOUS MATERIALSDISCLOSURE
mom or
WIII the,applicant mfumm buildinge, sono, handles
AS dented by Ila Cupertino Municipal Code. Chapter 9.13, and ac Halm and Sa(ny
Chapter halt ad
Code. Section 25532(a)7
All roofs shall be inspected prior to any roofing material being installed.
Oyes ON.
If a roof is installed without first obtaining an inspection, I agree to remove
Will me applicant or future Wilding mupant use equipment or devices which
emil hmardna air contaminants a dcflmd by the Bay Area Air Quality Management
all new materials for inspection.
Diwict7
❑Yes 0 N
I ban mad the huwdms materials requiremenu under Chimer 6.95 of the Califor.
me ficahh a: SaletyCodc. Section 25505,25533 Mai 25534,1 understand that lfft Wilding
does rent commit haw a uvea Shut it is my responsibility to roily she occupant of An,
requirements which mat be mel prior to issuance aft Ccrdlicam of Occupancy.
Signature of Applicant Date
All roof coverings to be Class "B" or better
Owner
oraamorixodaSent Dom