04100044 CITY OF CUPERTINO fol"I t r�
BUILDING DIVISION 'PERMIT rXONa "0TQR IN ?MON
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BUILDING
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o#7,.G c3n:,P,l_.'
BUILDING ADDRESS: """04100044
ERMITNO04100044
OWNER'S NAME: PERMIT ISSUE DATE
TOM BECKETT
E: SANITARY 0. CONTROL NO,
ARCHITECT/ENGINEER: BUILDING PERMIT INFO _
BLDG ELECT' PLUMB MECH
Z, LICENSED CONTRACTOR'S DECLARATION Job Description
rO O O 0
I hemby affirm that 1 am licensed undepm' as of Chapter 9(commencing
n li withS�on )of DiNdon3ofeo eudnem ofessiuns Code,and my license is - - -
a infuli and eH
Loan CI Lte.h�3Z/5'3'i ADD 2 WINDOWSCon -
rgDam TS DEC CONTRACTOR: SUNDANCE CONSTRUCTION
ARCHITECTS DECLARATION
1 undernaml my plans shall he used As public rte
3 License)Pmfcasional
OWNER-BUILDER DECLARATION
E 0 2 heresy Affirm on 11. exempt from the Cr iondCo License law for the
$ following roman.Permit
In
]In L5,construct,af•••and sae,de oli Code:Any city nr county
which requlrrs a permit re .Ill. almO improve,demolish.1 or repair any ammoam
Prior mits ceased .alsom In the thoaamas of fnrgmh the Comrachn mcensefile Lwdgatemcm
p Q Nu he is licensed porstfix.7 lM of Division
iatom of Co.Businmrsniwnragum(Chapterrum ., Sq. Ft.Floor Area Valuatl[_sn
y $ (co he I$esawith Ssafram and
basis n3 thereeged Businessland Anynvi Code)of 4180
that io r exempt Cmrefrom and the aper for the alleged exemption.Any it penalty
of
SectiOut non]O3LSby myapplicantdontfor a s(SSM permit subjects the applran4o.civil pendty nl APN Number Occupancy Type
not more Wn Bw hundred dollars(5500).
❑1,As owner of the property,army employees with wages u thelrsam compensation, 32651010 . 00
will do the work,and Ne awcmm is not intended areffered folmm(Sec.7W4,Business It
and Profecdons Cade:The Conuacmrs U..law does not apply m an owner of RV
1 I B [ttWW��D
property who buildA orimprows thereon,andwho doesrvch work himself arthrough his
L
Own employees,provided that such impmm
veenu art nal intended oroRered hassle.If, '
however.the building or improvement is sold within one year of completion,the ownery
Guilder will have the Wed.of proving Wt M did not build or improve for puryme of
peat.) Nov u 2004
❑L m owner ej the property,am ex.=Ad convening with:)Th.Contractor.
opnv¢mn m
congmet the es not (Sec.]Baa weer or and property
whoWild,
Code:) proves thammn, rad
whocesscontracts Intra f not apply m is owner of rach ny who Guilds or improves Contra,and BUILDING■ ■I■ ®�
Lfar such projects with e<onuacmr(s)Iiamed punmmmlhe Conuacmr'e •®J U L
01License 4w.
❑1 am eacmpt under Sep ,B d P C for this moon
Owner Dao
WORKER'S COMPENSATION DECLARATION
1 hereby dorm under penalty of perjury one of the following declamimu:
haw end will maintain a Certificate of Consent m selNinsum for WorkcYsCompen-
an,m provided far by Section 37M of the labor Cade,for the performance of the
work for which this permit is issued .
❑1 have and will maintain Worker's Compevaean buunnce,As required by Section
37M of thc Labor Code,for the performance of Ne work forwhich this permit is issued.
My Worker's Compensation Insurance carrier and Policy number are:
"Caller.L f7"F e e L. A/0 FOR y No.J5' z��g t
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSUANCE
(notaccCw need nm W camPlemd ifthe permit lsfmonc hundred unit.(SIM)
or lost.)
I cenify lug in the performance of the work for which this permit is issued,I shall not
employ any person in any somacran As he become subject to the Worlaeri Compenmdon
Laws of CalifomiL Dem
Applicant
NOTICE TO APPLICANT:It,after making this CertiBcam of Exemption,you should
become subject m the Worker's Compensation previsions of the Labor Code,you mug
.J z forthwith--Ply with such monism.or this perout"I M deemed mvnked.
z CONSTRUCTION LENDING AGENCY
[—i I herebyoRum that inert iaacomvuctun lending agency In,the performanc of
Co work fur which this permit is issurA(Sec.3097,Civ.C.)
Ig7 Q Umer's Name
CL Lendcr's Addreas
V C 1 cemfy that 1 have read Nis application and sum that the.bow infmmalk n is
ly !` correct.I agree m comply with all city and county ordinance,and sum laws mating to
rV' auilding convection,and hereby auNonx mpmxnutives of this city to enter upon the
Lg ehove-mrmionad property her inpecfitn pmpnm.
(We)agree an save,indemnify and keep harmless the City of Cupertino against
VI Ihbilitics.judgmonu,costs and a.,.which may in any way eenbe againtmid City
(„) Aco7nwquef the gmming aft permit.NDERSTAND AND WILL COMPLY WITHML NON-POINT Issued by: DateLATIONS. ✓' Re-roofs
Imu VCoa per Data
HAZA 0 MATERIALS DISCLOSURE Type of Roof
Will Cm applicator at WHding occupant more or handle hazardous mamrial
As defined by IM Cupenin nicipel Code,Chapter 9.12.m0 Cm Health and Safety
Cak,Section 25532(¢)?
❑Yat No All roofs shall be inspected prior to any roofing material being installed.
If a roof is installed without first obtaining an inspection,I
Will the applicantbrlumm Wilding Occupant use equipment or devices which g agree to remove P
t hozmdl m air contaminants as defined by the Bay Arca Air Quality Management all new materials for inspection.
.vier?
C]Y.
No
I haw mad the harardnusmaorids requirements under Chapmr6.9]Ditto Califo>
nix&n=L'Iy,=,
SceIIx25505,25533 and 25534.Iundenand thuifthe Wilding
Jaew a that it u my mspomlMlity m notify the occupant or the
cmnm.tp or Inissaanccat.CcmflC.mofGee a Signature of Applicant Date
/ a e
owner or anmarircd aseni ,m All roof coverings to be Class"B"or better