05040093 CITY OF CUPERTINO
BUILDING DIVISION P
BUILDING ADDRESS: ANN SIMPSON PEIIMITND05040093
22044
OWNER'S NAME: PERMIT ISSUE DATE
ANN SIMPSON
NE: SANITARY NO. 8 2 CONTROL NO.
ARCHITEC(ENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
o
�10o LICENSED CONTRACTOR'S DECLARATION Job Description
pp 1 hereby afRrm m that 1 license under provisions of Chapter 9(eventuat(eventuat(eventuatingo
ing
with Section 70(10)ofDivicon 3 of the Businwand Professions Code.and my license is
LIC.
11
ll to.anae@a
License Clens BATHRM REMODEL/INTER. REPIPE
Dam Ct
ARCHITECT'S DECLARATIONON
I understand my pons Mel be used as public menrN
0yU
il:50)d Licensed Professional
OWNER-BUILDER DECLARATION
CI gritty affirm that 11. exempt from the Cantonal License law for the
C O following maeoo.Permit
7031.5.Business no ve.de Ons Cod,:My city st county
$m which mqubca•Permit re sores t e4 alter. ,for s0)demolish,nr e&sig any structstatement j, prior w its issuance,stan requires the thovisio s O far COn permittm2 ices Law(Cammenl
(coftL mmencing
wit pursuant to the of Division
of thehe Business an cense Law(Code) 9 Sq.Ft.Floor Area Valuation
B (commencing with Section 7000)ofbarb far
or me
Ruaineuandon.My
Code)or
this ha u exmDt thme(rom and dm buns for the stlegetl exmpHon.MY Hol W'an of
di
nomi ore OiMn fi31.5
hany aarpealic it f r a permit subjects d:e, applicant m a civil penalty aetO 0 Occupancy Type
*I,u owner of He property or my mploym with wages u Ihair sole compewlme,
will do the work,and me manse.u not intended or offered for male(Sec.7044.Business
'and Prefessmns Code:The Canveno/a License waw dm an,apply to an owner of Required Inspections
manpropertymploys,proarlmproveach Impr mdwho dmauch wart oraffeor through his
own employee•provided that vemimprovemenam not Intended ceOffemd for owmer-
oull
however. ft or ImprovementleantiwithinoroYd ofcmove far purpose will have Ibe burden of proving that he did not bWle ce improve Ice pugOse of
const
❑1,a Owner of the property,am e,chalvely concerting with licensed contractors to
cense La the es se(apply o an Business and property
who ns Cade:)The Cantncme.Li-
cense law does not apply to is wnar of property wce Wilda rs Improves tow Norton.and,
whom Law, for such ptoJecu with acanpsmr(a)licensee purawmwWe ConlranoYa
[3 1 am Law.
❑lam//yy{{em,pt undue See. ,BkPCfor this rcuen
Owes,INg1• Date y�14�o5
WO ER'$COMPENSATIONDECLARATION
I hen ey affirm 0)M r penally of perjury om of the follwing dwi"ionr.
I haveand wW mstnuin aCenifinte of COnsem w self-insure Ice Wcekar'aCmpen-
atian, provided(or by Section 3700 of Ne labor Cotle,far Ne p,rfamanm of the
work for which this permit is laved.
❑1 Mw and will maintain Worker's Compensation Insurseem,as retained by Section
3700 of the Latter Code,for the performance of the works fmwhich this permit is issued.
My Worker's Compensation Insurance envier and Policy number m:
Caroler. Pallcy No.: _
CERTIFICATE OF EXEM MON FROM WORKERS'
COMPENSATION INSURANCE
(This section meed not he completed If the permit Is furane hundred dollars(SIM)
of let
I madly that In the performance of the work fm which this permit is Issued.I sWI a(
employ any person in any mamcrtmII♦ esu�ecIto gmworken'Compensation
Iawsof CaT rnia�pm 0
ApplicantI&& /g
NOTICE TO APPLICANT.If,arm,making this CeNOcam of Excmpdan,you should
become subject m the Worker's Compensation prmIllons of the labor Code,you mat
.JZ forthwith comply with such provisions or Nis permit heR be deemed ranked.
Z O e CONSTRUCTION LENDING AGENCY
I-t IherebY arrm Nat thane is a eotuuucdnn lending agency ter dm performance of
iYi�y the work for which this permit Is issued(Sm.3097,Civ.C.)
Q Lender's Name
,,z Lembr's Address
V Q I certify that I have reed this applicadon and mm dtu the show informed.is
I[.Pcorm"l agree to comply with all city and county ordinances end sum laws misting to /
building cons ruction,and hereby eudtodm u
repmnu iM Ofdog city to enter upodm
n S
W above-mendanW property,for inspection purposes
py (We)agree te save,Indemnify and keep hamlless dte City of Cupertino against
IA liabilities judgments,costs and expenses which may In any way accrue against uld City
U 7 In wnsgmnm of the granting of this permit.
G7 APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT Issued by: Date /
SOURCE REGULATIONS. 3,/���w y�IH'D�
2 7y Re-roofs
Signature of ApplicisaXontrsto Data
HAZARDOUS MATERIALS DISCLOSURE Type of Roof
Will the applicant or futon building omupsel(m"handle hazardous material
as defined by Uw Cupertino Muni'pal Code,Chapter 9.M ado the Health and Safety
Cade,Section 25572(x)? All roofs shall be inspected prior to any roofing material being installed.
❑Yea No
Will the applicant or mtum building Occupant sac equipment or deem which If a roof is installed Without first obtaining an inspection,I agree to remove
mit hamdous air contaminants as defined by the Bay Area Air Quality Management all new materials for inspection.
District? //
❑Ycs aK. -
Ihavem.dthebuardmsmamrlalse uimmenuundorChepmr Q95ofthe Califor-
nlaHmlth@SafctyCado.S,ctiom25505,25533ud25l34.lundcruundthatifthe building
dm not currently how a tenant,dua It is my mapaalhillty,w nodl'y d0)mumni of dm
,Nhcme rah M met priorw wummcofa Ocrdficam of
-,X _ _ Y°j 716 Signature of Applicant Date
OOwwn,r rauthadsdege +�""� '/ Dom All roof coverings to be Class��JJ��or bCllei
l9.cr '+
rtVY�t 4f"
r -7. '3d t 5�•�.�R�
• S! t EN'ZzI � PROMC ,� StHEE r
M x
CUPEI,TINO j� _f t_ F:-..: .
Assessor's Parcel Number:X32 6 O _'9 O 4/
Nameofowner. `INN 4impfan
Project address.. 1,� l a ce Tf j Ve gaper r�rlo C,0. 4 SO/y
Contact person. 74U 4,01100n Phone.
Fax.
Net square footage of lot. _@41�� q�o0
Existin Proposed
Square footage: First floor:
Second floor:
Garage:
TOTAL:
• Are there at least two 10 foot by 20 foot clear spaces inside the garage? Y N
Is privacy protection planting required for the project? Y . N
On what floor(s) is work being done?
Brief description of work.
Code editions: 2001 CBC (Y -N)2001 CFC (Y -N)2001 CMC (Y-N)
2001 CPC (Y -14)2001 NEC (Y -N)
Effective 11/1/02
n
CEI V Lt.'
OFFICECID PY - APR 1 @ 2005
Plan Review Process Work Book Page-8-Revised 4/28/04
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