01120004 CITY
I BDIGDSNO
BUILDING DIVISION PERMIT CONTRACTOR INFORMATION:
ettlLttlp'ri/}YRTERRY WY JOE WING G AND KIT F ET PL nND y 01120004
O'J' 'yV tNG G AND KIT F ET AL A�L� rdj 2011
PHONE: SANITARY NO. CONTROL NO.
1
O O
ARCHITECT/ENGINEER: BUILDING PERMIT INTO
BLDG ELECT PLUMB MECH
NLICENSED CONTRACTOR'S DECLARATION ,fob D ftOn
JZ4� Ih<mhyoffinn that lam licensed under Imlismo.f Chapter 9 moonstal i, REPLACE 4 WALL HEAf1' S
with S<CIIoa 71K1n)of Division 3 of the Business and Profc omm.Code,and my license
C m I is in full force and effcn. t
a a K< License Class Llc.Ctiol E "
y,.; EDa¢ Lie.# errD�is1300 a.Yr ARCHITECT'S DECLARATION +.• /1 understand my plans shall be used as public records ',yLicensed ProfessionalOWNER-BUILDER DECLARATION
I hereby.Rrm that 1 am exempt from the Contractor's License Law for rhefanowingtearan.(Section7031.5.BusinessandProfessionsCade:Anycityoreounty L�
ISO which m,.ima a permit m construct,cher,improve,demolish,or repair my .to.
C3$ prior..its issdohra,,Iso requitesM applicant fu such permit m Be a signed smtemem --
ya.h<ialicen dPu Jnnbd poet onofh Co moo Lice awlChaper9 39X;]PV, r, Valuation
g with - a ( e.�l o
Icommrncis m exempt therm oth ird the basis o t the Braine x and Professions Cale)
or that he 731.5 bany p m'and the basis for the alleged exemption Any it Mail,,-.feet oncre than five
hundred
for 500). subjects the ePplirnmmacivil penalty' MMAIL PLUMBIN ENERGPccupancy Type
ern.//t more than rv<n.narea a.nare asoo. 5 0�P�I
26t sowncr ti property,or my employees with wages as their sole compensation, 506 - GAS TEST
will do the work,and the structure is not intended or offered far sale(sec.7044, 507 - FINAL P ��T�.
Busivas'und Profession Code:The Contractor's License Law drat not 111,.o an IR 'NUar•ASpeCt10H5
owner of property Who builds or improves thereon,and who docs such work himself
or tit gl his own employees provided that sucharsimprovements isare m intended or .. .. .-._ ._
,of(eredT r sell IL however .he bmld ng or Improvement i let within one year of'. " "--' -
completion,the owneobuilder will have the burden of proving that he dud not build or \
improve for purpose of salcJ.
_.❑I,_ asowne ._.. ..
r.!Ne property,a exclusively a commcung with ddc:)s"a Contrtms to
construct the does
Project(Sec.lto n,Business aril Profusions lila or The Contractor, m I.
- - License Lew does not r such
ton owner of property who builds se improves thereon,
axil who contracts for such protects with a comrumrts)licensed purmam to nm .. .. toot .. .. ._._._.__.
Canteens',Licrnse law
__ ❑l am aempt tinders B&PC forthismason ^PT"
Owner 1/ Da�
W KER' C PENSAT�1 D RATION
1 hereby aRmm under penalty of perjury ane of the following declarations:
0 1 have and will maintain is Certificate of Consist on self-insme for Worker's
Compensation, as provided for by Section 3700 of the Labor Code, for the
_ Performance of the work far which this permit is issi
01 have and will main..:.Worker's Compensation Insurance,as required by Section
3700 of the Labor.Code,for the performance of.he work for which this permit is
=. Compenation Insurance canner and Policy number arc: _ _..,.....
. Issued.MYWorkers. ._ s .. ._. . ... toot - toot
., .. Comer. .. ( Ste c.,.g'i:..Policy No.i
CERTIFICATION OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE'' _ ._-._ . ._. ..-___.__....--,..__... ..- . _ ._.-... .........._..,.._.-toot
. i .. ..
(`Ibis section need not be completed if the permit is for one hundred dollen
HIM)or less.)
1 certify @n in.rte performance of the work for which thio permit n Workers'Workorke 1 '
shell not employ any person in any manner sec n m become subject in eto r:
Compensation Laws of California.Dam
Applicant
'NOTICETOAPPLICANT:IL after making this Ceeificat of Exemption,yo.,hould
Z become mbiwi.the Worke ,Compenmtionpmvisionsofahe Labor Code.you must
Q Q forthwith comply with such pmvisim,or this permit Jmll be deemed mvoked.
CONSTRUCTION LENDING AGENCY _
1 hereby wRml this phew ii,conduction leading agency for me perfomlmtt
W me Work for which thi6 polio:.is issued(5[[.'3097,Civ.C.)
Lender's Q nder's Neme. .4 ... ,-. ...
Z Lendcr`v Address _ -; _ •, „ , -
C.I 0 1 certify.hat 1 have read this application and vise tbar he above information is
'correct,1 agree to comply with all city and county ordinances and vote laws relating
to building construction,and herebynuthodu representutivesof thii city to enter upon
the above-mentioned property for inspection purposes.,,
I]e (We)agreem save,indemnify and keep hitrmleu the City of Cupertino against
liabilities,judgments,costs and expenses which may in my way accne against said
V Z City in consequenceof the g ting of this.permit.'
_ - APURCE REG�TST SAND/W COMPLY'WITH'ALLNON-POINT' Issued by: Date
I
'gmwre olA man on or Dam Re-roofs ^ - 3
' HATH US'MA IA DISCLOSURE
: . W li ihe'.pphaml or future bund:g Weapons store ouNa
r handle hau material
Type Of Roofas defined by the Cupertino Municipal Code,Chapter 9.12.and the Health and Safety -
Cade.Saban 25532(a)?. +
"❑Yet , ,QNo'.•, '.. i q..i°- •.{
_ All roofs.shall be inspected.prior-to any,roofing material being installed.
WiIINe,pplicmtorfmureEuilet�ng«cupamuucquipmemordevicnwhich If a roof is installed without first obtaining an inspection,rl agree to remove
emit haiirdob,air contaminants as defined by Ne Bay Area Air Quality Mmagemml
District? 1 all_new materials for inspection. Applicant understands and will comply with
OY S ❑N. all non-point source regulations,
C.9 '1 have need the haudous meanals requirements under Chapter 69 of the
California Health&Safety Code,Sections 25505,25533 and 25534.1 understand that
if the building does not currently have n mean,.hat it i,any nespondblloy to partly the
occupant of the i quire pm which must t prior to issuance of a Certificate of
Occupancy. .. .. .
Signature of Applicant Date
Ilermmmnriaea rot ,q.,e All roof coverings to be Class "B"or better/Ow -
..� j':.. . ..:.
OFFICE .. ._ __. . ..