07110118CITY OF CUPERTINOanaM.v„skpwx,{reStar;(:.e��.
BUILDING DIV PERMIT
E'��}}���Yb'� ♦�`��yy'€"�
S,�Q '1�.�Ei TQ AL�FQ�iMtlt��.Tl'1 .
. % u�•+XAs`-1"i is ,+-, RM.i+gYq i fir: a�N �.� Y, e-'i� , $
Bul"I�It�GOD� OODRIDGE CT
TBD - TO BE DETERMINED
�r�+q
P57YA118
R'S NAME:
PERMIT ISSUE DATE
04/09/2008
PHONE:
SANITARY NO, CONTROL NO.
ARCHITECT/ENGINEER:
BUILDING PERMIT INFO
BLDO ELECT PLUMB MECH
LICENSED CONTRACTOR'S DECLARATION
lob Description
I hereby "on that 1 am Ikemcd under provisions of chaper 9 (eommeming
with Section 7000) of Dividon 3 ofthe Ban. rcuions .red Ikcnmh
SFD RMDL KTCHN, LAUNDRY, DINING & MSTR BATH.
in full Tome and effeep
Ueenm Clan Lie.0
Date Conuaeuda Lammv
'
ARCHITECT'S DECLARATION
I undermanJ my pli m eNll be tared u public records
..
Licensed Professional
OWNER-BUILDER DECLARATION
I hereby aRrre that I nm uempt from the ConlnnoYs License Law far the
following moron. (Section M31.5, Business and ProlloWuns Code: Any city or county
which re9utmn a pumir le conmoct sber. improve, arroll sh, or repair my someone,
Prim to i%isst mce. Wu rtqulru the apPlicmt for Inch permit m file a signed statement
that he is licensed to the of the Conuacurs License Law
Sq. Ft. Floor Area
Valuation
pursuant provisions (ch.pw9
$80000
(commencing with Section 7000) of DMA.. 3 of the Business and Profesaiom Codo) or
that bo is attempt therefrom and ft basis for the alleged exemption. Any Waladon of
ik7kt Number
34215061 )IMTy'Pe
Occupancy
Section 7031.5 by any applicant for a permit subjects the awlkanl to a civil penalty of
rert 500k t more than five hundred dollars
❑ I,uowne of du propery,emy wploym with wgn utheir mk compewJan,
Required Inspections
will do the work, and the Immune, is not intended or offered for We (Sec. 70/1. Buskins
and Professions, Cade: The cmbmurs License Law dean our apply or m owner of
progeny who Wilds crimprevu Jmman, and who doessueh work himselfor through his
own employees. provided that such improvements are not intended craRend farina IC
however, the building or improvemmr is sold within one year of completion, the owner-
builder will lu ret the Nodded of proving that W did not Wim or improve for purpose of
ule.).
0 L as owner of the property am inclusively commuting with framsed contractors to
construct the Project (See. 7044. Business and Ro(asslom Cotler) The Conoactar's Li-
come law does not apply m an owner of property who Wilds or Improves themon, and.
who concocts for such pr*cu with a conwcur(s) Iicemed rumors, he the Conmmmes
Licemm Law.
m "am .11APCfmthiareuon
u Date
WORKER'S COMPPNSATION DECLARATION
1 hereby arbors under penalty of perjury one of the following declant ods:
1 h.ve and will ..low].. Certificate of Came n, m su
self-inre for Waaker. Camper
t , as provided for by Section 3700 of the labor Code, For the performance of the
wort for which this Permit is isaoctl.
0 1 have and will maintain Wmkars Compensation Insurance, as required by Section
3700 of the Labor Code, for the performance of the weak forwhich this permit Is Weed.
'
My Workers Compensation Insmmm carrier and Policy number are:
Cartier. Policy No.:
'
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(Dws ancient mead not bocampleted If Jc permit Is foronc hundreddnllan (SIM)
m lou)
1 certify that in the perfomunce of the work for which this permit ts issued. I shall not
employ any ppm my m u m bo s o W !hi Compensation
.
Laws of Cali(
coding this Cemficam of=m Ppm
become subject m Out Workers Compensation previsions of the labor Code. you most
foMwith comply with such Provisions or this permit Nell bo deemed revoked.
CONSTIUCITON LENDING AGENCY
I hereby affirm that then is a conservation lending agency for the Performance of
the work for which this Permlt Is mused (Sec, 3097, Civ. C.)
Landers Nam.
,
lender. Add.
1 card ly the I Tuve was this application and sou Nat the above information Is
'
correct. I agree to comply with tl1 city and county ordinances and sue laws relating to
Wilding construction. and hereby authein representatives, of this city an enter upon Jos
above-mentioned property for Inspection purposes.
(We) agree to save, indemnify and keep harmless the City of Cupertino against
liabilities, judgments, costs and expenses which may In any my mere against said City
in canscgmnee of the granting of this permit.
APPLICANT UNDER NDS App W7jyyL COMPLY WITH ALL NON-POINT
Issued by: Date
SOUR EGUI.t S. , //�/
�(!�/J
/� w�'
Re-roofs
SI urto AppliceHAZARDOU D�—
HAZARDOUS MATERIALS DISCLOSURE
Type of Roof
Willy the m forum Wilding
Wilding acme or handle hauNoos material
'
e Cupertino e. Chapter
aned DY the Cupertino Municipal Cade. Chapter 9.13. roti Jc Halth and Safely
ft
. Secula. M5374)7
All roofs shall be inspected to any roofing material being installed.
❑ Yn c
prior
If a roof is installed without first obtaining an inspection, I agree to remove
Will Jm applicrut orf pre Wilding =pant um equipmml or devise which
emit haurdou. air cantaminams as defined by Jos Bay Arta Air Quality Management
all new materials for inspection.
Dimicl7
O Yes mdfu
I haw: rural the h awlawmnnialsrequlrcmcnu under Chepter6.95 ofthe Cdifor.
f
'
nia He.lth Sefcty Cade,Sc-i..M505,15533and2534.1ud4mu ffthc Wilding
out
den nom, have . te.4.4 dII' m Feasibility to notify the.,.Pmt of the
mogul en w
which w en III ecof. Ceile.maf0
ignature of Applicant Date
W�!74AQe
Y�7
All roof coverings to be Class'%¢.' or better
Dome r nr authn� J eSent