04090063 CITY OF CUPERTINO 777.77777777777-77777 �, g"A
BUILDING DIVISION PERMIT
BUILDING ADDRESS: PERMIT NO,
PERMIAN BUILDERS INC. 04090063
AM eREEfE
PERMIT ISSUE DATE
AIL- TAITTATT "' ISTEGNER
WE: T"E'STINGHeydSE BR. SANITARY iPO9. /3:3 2 Q9*01,NO.
ARCHITECT/ENGINEER: BUILDING PERMIT INFO
BLDG MECH
c`86 ff PIT
.0 LICENSED CONTRACTOR'S DECLARATION
IdF, I hereby affirm Met I am licensed undo,prooviiii.m.mf Chep e,9(commencing Job Description
with Section 70110).J[Dhebocun Sof the Bitairsamicind Prefossiome Code,and my license I.
I.pill force.oil affect.
3 Lt...Clear-Lie. REVISION--HANDICAP/ RAMP
Z-, Dam-Contractor.
ARCHITECTS DECLARATION NO NEW PERMIT ISSUED/ORIG. #03120023
I unticistand my plans shall Wused as public records
8 Licensed Professional
is
OWNER-BUILDER DECLARATION
I hereby affirm that I me exempt from the Contractor's License Law for the
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S:M O following mason.(Section 7031.5,Business and Pradlessions Cc&:Any city or county
which mr,tims a Permit to construct after,orpronn,demolish.or repair any structure
prior to its issuance,also requires the applicant forsuch Permit to File a signed statement
that he is Imenrod pursuant to the provisions of the Commuclor's License Law(Chapter 9 Sq.Ft.Floor Area Valua''
(commencing with Section 7")of Division 3 of the Business it Professions Code)or '?`400
that be I,exempt therafteen and the basis for the alleged atumi Any vhdation of
Section 7031.5 by any applicant for a Permit subjects Me applicant to a civil Penalty of APN Number Occupancy Type
not mom than rm hundred dollars(M).
0 1,as owner of Ne pro,oxity,or my employees with well"as their sale confirmation, 35907005 . 00
will do the work,and tocimucium,I.hat mum ded mattered tarsale(Sec.7044.Business
and Prefessions,Code:The Convector's License Law does not apply W an owner of Required Inspections
property who buildsonIce proves therson,and who does such work himself orthough his
.a employees,provided tionsitch inipmonomots ime not imaridalmoffered Faradic.If.
howe,mr,Me Wilding or improvement is sold within one year of completion.Me owner.
builder will have me burden of praying that he did not Wild or improv(in prince,of
wale.).
1,as owner of the property,am exclusively contracting with licensed contractors to
cons et the project(Sec.7044,Business and Podessions Cialm)The Contractor's Li.
I pp to an owncral'proPerly who Wilds orrimistrawrathemoon,ad.
cense taw
j,cas with a extruncei licensed pursuant to the Contractors
L Law.
rya in S 0C. ,B&Pcforffijs moon
In.
Ow r m-8,a
R'S COMPENSATION DEC�CRnTON
mby effort under Penalty of perjury one of Me following declarations:
have and will maintain a Ccofficale of Consent to self-insure for Worlares Compoi.
ion,as provided for by Section 37M of be Labor Code,for Me Performance of the
work for which this permit is issued.
0 1 have andl will saturation Worker's Compensation Insurance,as required by Section
3700 of Me Lbor Com,for Me performance of the work for which this Permit is issued.
My Worker's Compensation Insurance carrier and Policy number cure:
Cartier. Policy No.:
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(rds imelim,need no,Im completed if the Permit is forms,hundred dollars($100)
or less.)
I cendy that in Me Performance of Me work for which this permit is issued.I shall not
employ any Nixon in any mustracran as to become subject to the Work ni'Compensation
Laws of Califomia,Dow
Applicant
NOTICE TO APPLICANT:If.after making this Certificate of Exemption,you should
become subject In the Worker's Cornixereation previsions of the Labor Code,you must
Z forthwith comply with such previsions or this permit shall he deemed rewired.
z 0
M CONSTRUCTION LENDING AGENCY
I hem by.M.Out be.is...inurtmfirm lemlottilmicy lathe isofminninue of
CC > ine work for which MI, .it is issued(See 3W7,Ci,C.)
Q Landerttom
z LeadeLeader's bor's Add.
1 certify that I have tend Bou application end scale Met the slonc fiformathin in
correct.I alime to comply with all city and county ordinances and able laws reading to
0 U building construction.and hereby authorize reforesentelbas of this city to enter clout Me
ahmm-riendonood pruperty for inspection purposes. oxim gaott
(We) g a,imitcroof and keep ocroolices the City of Cib,
!iabilities.jud; c trandexomoreawhichroquarty.,acenumagainst sa, y
in c se once a n'a' 4
AP granting oft
COMPLY WITH ALL NON-POINT Issued by:
'in'a'
g3nrAN 11
g_
S U E )Na§. Date
Re-roofs
Sign drApIpIciarbir.ouract., Date
HAZARDOUS MATERIALS DISCLOSURE Type of Roof
;PTLIJ Me applicant or future building occupant store or handle lumanjous material
as defined by Me Cupertino Municipal Cade,Chapter 9.12,and the Health and Safety
Coda.Section 25532(a)l
secs L' roofs shall be inspected prior to any roofing material being installed.
X. use the applicant or future building occupani ic equipment or devices which If a roof is installed without first obtaining an inspection,I agree to remove
hamodous air examinations as defined by the Bay Area Air Quality Management all new materials for inspection.
❑yes
to I
Ilia.. I, ins materialsoubberrocrus uncerCluipter6.95 ofthm Califts,
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lnix��.IMJLS t edc.25505,255330 25534.1tinkgrommithairMcInilding,
it..net c. it a lemon,com to 1-00p.1raftefli,y to redly the occupant I be
.4mmom idp6 �ftd
Must -�e -
requirermn W .11-ing, i..iacc.fsC,mfi.adc.fOq parnm� .
Signature of Applicant Date
Ir U110ti7. Dple All roof coverings to be Class"B"or better