04040104 CITY OF CUPERTINO °' `
BUILDING DIVISION PERMIT COIVTRA.CTQR INFORMATION
BUILDING ADDRESS: PERMIT NO.
ABCO CONST 04040104
OWNER'S NAME: PERMIT ISSUE DATE
IE: SANITARY OL NO.
ARCHITECT/ENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
uOp LICENSED CONTRACTOR'S DECLARATION IOW Descriptio
1 hemby sMm Wt I am tlRnstd under provisions of Chapter 9(Commencing
with Scotia.701Il0 of Divhd.n 3.(the Business and Profession.Code.end my license is
in full forte and effacL
5'�� LeonmCla, CLic.Oat DRMO (E) HOUSE �/� ,4C
s. Dens Cun DELL
ARCHITECTS be,used
2� s -
I understand my plans ahml he uad u public rtcnrN J
3p Licensed Professional y
OWNER-BUILDER DECLARATION
1 hereby.(firm that 1 am1. exempt Imre the CanmmCo e:Any c Law for the
20 followingmuoa Permit t 7031.5,Business enden.de inns Code:Anycity orcounty
$�i which rtqulreae,abs,mcnnct the slug impmsu demolish,are a sig anyewcum
ment
prior,instssuam,aluarngo due provisions of(msuchpermit mice ssignedautemcnt
g�g�< Nm he is ocing wit puation7 )previsions of the Camsiness nd ProcLaw ksomChapur9 Sq. Ft. Floor Area Valuat on
J! (cammms."Crapt Section and the basis far ofthe
eged oxermi mafAny v.CnM)ter
the,io is 31.5 b anrtfrem and the bur far tlse u the campdan.Any violation of
Section7a ass
Cary reddontforapermit abjecu the applicatwaCivil Penalty of 3--n.u1.i2 n..1.gr00 Occupancy e
not mom thus Bm hundred dollars(S5f10). !U C`�V'YV` p Y TYP "
P 1.as owner of the prepeny,or my employee with wage,as their sok compcmudan,
will do the work,and thesmauin r not intended or offend for sale(Sec.7004,Business
and Pmfesslons Cade:The Conuutor's Liceue law does not apply to an owner of Required Inspections
Import,who builds orimpreves demon,and who doesachwork himself orthreugh his
own employcea,prevailed that such improvements art nminended or oQemd forala If.
however,the building ar imprommem Is sold within one year of completion,the owner.
builder will have the Wumcn of proving that he did not Wild or Improve for p.m.of
ale)
1,as owner of the property,am exclusively contracting with licensed contractors to
cc trues the pmject(Sec.7014.Business and Pmfeaons Code:)The Contractor's Li-
cena law does no,apply to an owner of property who Wilds or improves thoreun,and.
who concocts for such pre icut witha conmcto M licensed puauam to the Contractor.
License Lew.
❑lam'sompwnd Sec. 7 .B&PCT
Ow
W .NSATION DECLAI
1 hereby afro under pe airy of perjury one a(thc(allowing dalaruiom:
be"and will position].a Certificate o(Co.am to self-insert for Worker.Compcn.
tion,u pmvlMd(m by Section 3700 of Ne labor Call,for the perfarmmce of the
work for which Nis permit is issued.
❑I have ted will munuin Workers Compensation Insurance,u mquirtd by Schon
3700 of the latior Code,for the perfarmuce of the wart for which On Permit is Wound.
My Workers Compensation Insurance Carrier and Policy number art:
Cartier. Policy No.: .
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(Thr action need not he completed if the Permit is fare=hundreddallsa($1U0)
or loss.)
1 cenify that in the performance of the work for which this permit is issued,I shell not
employ any pomp in any manner an u u,become subject to the Workere Compensation
Lawn of California.Due
APPliem
NOTICE TO APPLICANT:U.after making this Ccnificuc of Eacmption,you should
became subject to,he Worker's Compensation previsions of the labor CMe,you mus,
.JO forthwith comply with such provisions or this permit shall W deemed invoked.
'zy CONSTRUCTION LENDING AGENCY
r^i Ihereby alf..our them is a construction lending agency far the pufurman.of
the work fur which this permit is issued(See 3097.Civ.C.)
W 0
Loathes Name
r7 z Lender'sAddress
U Q I certify that 1 have mad this application and suns that the above infomia,iun is
W F corms 1 a&=to comply with all city and county ordinances and sou laws mladng w
DU building consurction,and hereby authorim upre¢nutives of Nis City to Omer upon the
W ihove-meManed property for inspection purposes.
(We)agree to save,indemn;(y and keep harmless the City of Cupertino against
y Iiabil;Ou,Judgam esu and a.,.,which may in Cay way aroma against said City
U Z tho tin&of this fourth.
APPLICANTe NDE SfAVDS IND WILL COMPLY WITH ALL NON-POINT Issued by: Date
p,
I E RE ULA7tO S. ' t
ii� l/ pan Re-roofs
Agnuum of lice, o.
A D US lATERIALS DISCLOSURE Type of Roof
Will llrceppli ,or lot=inni building ,Cbaplawinorlundkhuamousmalenal
u de,Sec io the 32(a)?w Macri'pal COM,LTaper 9.IT,and the Health antl Safety
Calc,Schon 2553](a)?
Oyer No All roofs shall be inspected prior to any roofing material being installed.
Will the applicant o Tutu building Occupant use equipment Or devices which If a roof is installed without first obtaining an inspection,I agree to remove
t havammus air mamri ea u MMOd by the Bay Arta Air Quality Management all new materials for inspection.
uvict7
❑Yes No
I have mad the Mvaad amour]is myuimments under Chapter 6.95ofthe Califor-
ataHcalNdtSme, ,Scniou25 ,25533am125534,1undrw.dthuifl Wildi.g
does not cuncn Waw en L that is my ramonsbiEty,as"dry the aeupat of the
rcquirtments ichin be et wissuasecofacenifieuorocc may. Signature of Applicant Date
o n<rar.m s „g All roof coverings to be Class "B"or better