04080237 •.CITY OF CUPERTINO-
Bun.DING DIVISION PERMIT.. CCSNTRA TUA T�F.ORMATION.
s1'i� :E�h
BUILDINGADDRESS: - PERMITNO.
DWK CONSTRUCTION 04080237
E M PERMIT ISSUE DATE
AIL
E;MAXTTn 1646 6 BE ANZA B13VBSANITARY OL NO.
ARCHITECDENGINEER: - -' BUILDING PERMIT INFID
lBILDO ELECT� O PLO O
300
LICENSED CONTRACTOR'S DECLARATION Job Description
�d 1 hereby affirm Net I son Handed under provision of Chapter 9(wading -
tl aids do O(10)of Dlvidan3oflhcBminecoandP ons Cad%memyliccnseis
in full sndeffecr
�: Lae ,.ej seer.. REMODEL F ,ADD 578 SQ. FT.
Data. ARCH ECISDECLA A N LIVING /FAMILY ROOM--1ST FL. & 2 BEDROOMS--2ND
1 and my plane shell W used as public cords
Licensed Professional
8y OWNER-BUHDaRDECLARATION
i 9 I beauty alarm that 1 am-map,from the Commmofs License law for the -
O O following mason.(Second 7031.5,Business sed Profusiam Code:Any city or county _ -
a}$ which requires a permit to mmmear,mar.Idmrow.dem ials,at repair my Rmetano ;
mm �' pri ialccc=dpu niwOsMvisiomofforsummwrIto OleaeUw(sukmcm
�< Nubs ecinawi p tionmNepm.iammafNehoB..i a ditrl,w(ch.pm9 Sq.Ft.Floor Area �/f��' Valli t
,CxS (commaneing intS fm and
ardecumume.MlOaCnde)or �S°Bp00
T� Nu h u nauapl UMrcfrom'mo oM basis for ose allegnd emanptiaa MY MWaoan o(." � ,' '
Sermon]031.5 byanyappnamfor epe•nbanbjeeuthe appinantmacildpenalty of . APN Number Uj/ '11 Occupancy TI pe'
not come than Bw hundred dollars(SSW).
❑L u owner of the property.or my employee with wages u their sate compensation, 32647019 . 00
will do the warn.andW urneure isnetintended or offered for add(Sec.7044.Business ' r�
"sed Profesiom Cade Th.Codrectpts License Law does act apply W an owner of - _- Requl pectionsV t
properly who buildsmimpmvnNerane.eM whodmeeuch work Mmsel(orthmugh his
ownemployeu,prodded thusmh lmprowmerns me notiodndnd aonered for We.if,
however.the building or Improvement in mid within am year ofcompleoon,the owner-
WIWer will love the burden of proving that M did not build a improv fm purpose of V
cons). V
❑1.u owner of the property,am exclusively commuting with licensed conlncmra to
conarmm the project(Sec. s in Bruer of and Proferty who
Code:)The Comramon. nd
ams law dose not apply a an owner of property who sed p arimprow Centro.and, -
U.
who.LAuu for proJecu with a convmlor(0lianend pursuant m Ne ConmmmrS
I-]I am few.
• ❑1 am exempt antler Sm. ,e&P C for this moon ..
Owner Dam
WORKER'S COMPENSATION DECLARATION
I hereby Since under penally of perjury oro of dM following declarations: . .
he.b and will mtinWn•Certificate of covens in self-ilium far Worker's,Camped- -
on.as provided for.by Section 3700 of Me labs Code,for Ne performance of Ne - -
work for which this permit is iatmd.
❑i haw and will maintain Worker's Compensation Insurance,u required by Seeoon - -
370D of Labor Cok,for d¢performance of Ne wort for which this permit is issued. .... ..-._.. —
My Warkefe Compensation Insurance aria and Policy number am: --
Cartier. Polity!
CERTIFICATE EXEMPno 1 WORKERS'
COM SATIOSURANCE
(Din seeder uMnd not MeomPkteM 1foM pemult is Imam hundretldollue(SI W)
mdse,)
I aN(y Net in Ne performance of the work for which this permit is issued.I shall not _
employ anypermn in any mmnerm as in become subject to Meworkeri Compencodon .... .
Laws of California.Data _
Applicant
NOTICE TO APPLICANT:If,after making this CeAfreaun of Eampoon,you should
become..him m the Wormes Corepenution previsions of the labor Code,you most
,QZ foahwgN comply with such quovisiom or this permit Mall M demand mussed.
�Q
ti CONSTRUCTION LENDING AGENCY
F IMI which
Mut Vert usmrmrec.3 lending .) for the penannanee of
ai theLa work(a which Nn permit U issued(Sec.3119].Cl,,C.)
Q Larder's Nunc .
.7. z Lendeta Address
I aN(y that I low read this application and sum that UM above informadon u
{4 f~ correct.l agree to comply with all city and county on it mas and sate laws mlating to
Q O building construction.and hereby maloom reprommamaa of this city to enter upon Me
ITh .Mve-mentioned propeny for Impection purposes.
Ly, LL (we)agree to ave,indemnify and keep harmless the City of Cupertino SOUL
liabilities,Judgmenu,costs and expense which may in my way emue against said City
(,7 In consequence of to gaming of this permit, f
u� APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT Issued by: Date
SOURCE REGULATIONS. _ /
0+'`11 --�—�—��
—=;=`1 •'� Re-roofs
Sign of Appilcen AConuacmr a�
HAZARDOUS M -RIALS D>t CL,OOSURE Type of Roof
Will the applicant or fmure Wilding occupant store a handle havardous materiel
n outland by Me Cupertino Municipal Cade.Chapter 9,12,and M Health and Safety
Code.SeNa.25532c... tuttt ��,�, All roofs shall be inspected prior to any roofing material being installed.
❑YuNo
Will MM applicant or future Wilding occupant ac equipment or devices which If a roof is installed without first obtaining an inspection,I agree to remove
I bacell u.sir oonuminanu as dunned by Lue Bay Ama Air Quality Management all new materials for inspection.
nrict7
❑Yu Nu
-V mad thehvardtms uunekrequiremenu underCMpter695 oftiMGlifor `,,�I
Ii.N ILK&Sef.LYCd•Saoeu25505.M533md25534,1undem ouirNc Wilding /S/)/ V —L r`O
does not amre a Manor.ow 11 u my mapomihifity m notify dw occupant of oM
amu which Ibematprior atissuance ofaCcnificemoi c cy./ atureofApplicant ate
��
Owner ser mthadved agent Dow All roof coverings to be Class.,B"- r better