04080041 CITY OF CUPERTINO
BUILDING DIVISION PERMIT MCONTRACTMjNF�012MATION
BUILDING ADDRESS: PERMIT NO
04080041
OWNER'S NAME: PERMIT ISSUE DATE
AL ROBERT
IFE; SANITARY ITC7 CONTROL NO.
ARCHTTECffENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
a�mOp LICENSED CONTRACTOR'S DECLARATION lob Description
vsF 1 thereby affirm she,l em limnxd under provisions of Chapter 9(commencing p
im3 wim Seaion70lM).f Divlsion3of me Busirmu erM Professiou Code.and mYliccocu
otI„ infull to=e.xCCI and offset.
ItIZ Liccnx Class Cic.x ADD 528 SQ. FT. (FAMILY/LIVING)
C.s
mewc
Dao: rS DE
ARCHITECTS DECLL
ARATION
I understand my plans still he uutl as public rtnrJs
�yU
Licensed Professional
3 OWNER-BUILDER DECLARATION
sC I hereby affirm that I I. exempt from J r Contras o Liccnx Lew for the
p o follwhich reuon.Section cars ,Business and we.dcr oli Cale:Any city or ru m.
m�
which nquira a pumit t.croswct,alcor,improv,sm.lisn,or repoir anY strvcsum
primto itsissuancc.alsomquims,hcapplicam farsochpcnniu.0lcasignedsummcnt
but he is licensed p...ofto the provisions of she Common's Liavc law Chapter 9 Sq. FL Floor Area Va uanon
mF (commencing with Section 7")of Division 3 of NC Business and Professions Code)or
to $ ,hat he is exempt therefrom and the basis for the alm sac!exemption.Any violation of
Section 7031.5 by any applicant for a permit subjecu the applicant to•civil penalty Of 3 9&N2ti4*Pr0 0 Occupancy Type
not more than five hundred dollen($500). P y yp
❑I,as owner of the property,or my employers wish wages u,heir solo Compensation.
will do me work and Ne sec corm is not intended oroffsod for sale(Sec.7044.Business
and Professions Cade:The Comenexo's Licerse Law does rot apply to in owner of Required Inspections
pmMny who builds or improv thereon,and who does such wart himself or through his
awn employes.provided that such imprewmenu are not intended at offered forsale If,
however.she building or improvement is sold within one you of completion,one awncr-
holder wif have Je burden of moving that he did not build or improv for purpose of
sam). tttt��Aa B
(7 u 1, owner of the property, mu
,am exclusively contracting with licensed ntr ,ors m Am
connect doe protect(Sec.7044,Business an Profession Code:)The Con,racmri Li. ®
ttnx law d nos apply m an owner of p Y who builds or improv there.n,and
who contra rsucnpro'cu w' aconuat r(s)li thud pursuant trlo Contractor.I -
�lam m der Se .B&PCfw section ([��ap
kg
O er - O Vj I /y�(�l (7e,
WORKER'S COMPENS D RATI `/`/`/{{{CCVIVIVIiii(MC/7`(//®
I hereby anon underpenahy of per jury of I(tloaving decanriau:
haw and will maintain a Cenifiate of Comcn,m self-insum for WorkehCompen-
sation,u provided for by Section 3700 of de labor Code,for,ha performamma of me
work for which mis permit is issued.
❑1 haw and will maintain Worker's Compensation Insurance,u required by Section
3700.17 me Latour Cos.far the perfarmuce of the work forwbich mis permit is issued.
My Workeh Compensation Insurance caner and Policy number am:
Carrier. Policy No.:
CERTIFICATE OF E%EMPTON FROM WORKERS'
COMPENSATION INSURANCE
(nissecu n need mot he completed ifJe permit isforone hundred dollars(5100)
or less)
1 certify that in the pefformana of she work for which this permit is issued,I shall not
employ any person in any manna,so as to became subject to the WorkersCompeuadon
laws of California.Dam
Applicant
NOTICE TO APPLICANT:If,arm,making this Ce.ifieme of Exemption,you mould
become subject to the Worker's Compensation provisions of,he Labor Canso.you most
0 z forthwith comply with such provisions or this permit shall be dimmed rovolmd.
zCONSTRUCTION LENDING AGENCY
(--t I hereby affirm that mem is aconstruction lending agency for the performance of
: the weM1 for which this permit is issued(Ser.3097.Co,C.)
Wer Q lender's Name
=z lender's Address
V 0 I mnify mat 1 haw mad his application and low mat One,show informatiun is
Pcornett I agree to comply wim all city and county oNiwttts and suss laws relating In
0 V building construction.and hereby authorime mpiesemativ of this city to color upon the
}V1 ah hili jtioned property for Inspection purposes.
(We)agree to save,indemnify and keep harmless me City of Cupertino against
trh hili judgmenu.cosa en capeun//s4renichmay in any way eccnlo against mid City
UZ eco ncc of Nc gram of mis/krmit.
^ AP I NT UND
0 RST DS A�91r WI COMPLY WITH ALL NON-POINT Issued by: Dale
5 CER GUL 1 �
Sm urco ApplivanuCantracfor `` am Re-roofs
HAZARDOUS A IA DISCLOA E Type of Roof
Will the applicant or fuom buildin 4PN,arom or hand.hmudous malorial
.MLu defined by she Cupeman Mun pal Cos,Chapter 9.12.and the Health and Safety -
os,Section 25572(x)?
Ayes No All roofs shall be inspected prior to any roofing material being installed.
Will she applicant or future building Occupant use equipment or devices which If a roof is installed without first obtaining an inspection,I agree to remove
. haramous air anuminfined by ft Bay Area Air Quality Management
inriel? all new materials for inspection.
C]Yes anu u
I.mad me bvardmws mvcrials yvi,cmcnutins,Chapa,6.95ofmcCalifor-
nis I Safety code.Se u25505 533 and...1unsmnollhatifthe Wilding
d not ne ly by a Le 1.Net i, a y ponibility m notify me..P.,of me
re COhich a, epmrmi o ofaCcoiranor imp ex Signature of Applicant Date
n y Q v
owns err, one.<dasem Dam All roof coverings to be Class "B"or better