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CITY OF CUPERTINO
BUILDING DIVISION PE RMIT
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BUILDING ADDRESS:
21776 COLLINGSWQRT14 RT
D & D CONSTRUCTION
PERMrr No.05110040
ER'S NAME:
PERMIT ISSUE DATE
JANE PAN
1447 HAMPTON DR-
11/29/200S
E;
SANITARY NO. CONTROL NO.
(408)666-5298
ARCHIIEC (ENGINEER:BUR.DING
PERMIT INFO
BLDG EIJ:Cf PLUMB MECH
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LICENSED CONTRACTORS DECLARATION
lob Description
ereby alarm 1 un licensed der em proas of Chapter 9 (commencing
1 hm W
with Section 700D) ofDividon 3oftic BuNeu and professions, Cods. and my license Ie
in full rmaarderzeaL
REVISION -REPLACE WINDOWS & BAYWINDOW
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Dau Lie.
Dam
NO NEW PERMIT ISSUED/ORIG. #05080137
ARCHITECTS DECLARATION
1 undcrsttnd my plans 'hall be teed as public records
Licensed professional
OWNER -BUILDER DECLARATION
I hereby aRrm that I am mrapt from the Comarcoes License Law for the
following moron. (Section 70315, Business and Professions Cade: My city or county
which requirus a Permit to convect, alter. Impmw, demolish, or repair any structure
print in is, issuance, aim requim the applicant forsuch permit to Oka signed matemem
Sq. Ft. Floor Area
Valuatiofp214
Had he is licensed pursuant to the provisions of the Conbmtses UceWe Law (Chaptes9
(commencing with Section 7000) of Division 3 of the Busamm and Profuseimns Code) or
Nat heel" eemPI IMmfecm LA the bath for the alleged esampOm. My violation of
APN Number
Occupancy Type
Section 7031.3 by any applicant for a permit subjects the applicant to a civil penalty of
m mom than ftw hundred dollars (5300).
3 5 617
Q I, u owner of Dte pmpmty, m my mployeu with wage u theirmlecompemuon,
Required Inspections
will do tee wont and theasmctum 0 ontinunded confined Insists (Sec. 71144. Business
and Professions Cade: The Conbacmr'a Licme law doe not apply u an owner of
property who Wilds or improves uwmn, and who does such work hImar3rorthrough his
awe employees, provided Nn each Improvements me hot mounted or offered for sola. IL
however, the Wilding or Improvement la sold wlWn ons year ofcompletion, the owner -
Wilder will haw the burden of proving that he did tet Wild or improve for purpose of
sale.).
ILL u'woes of rhe P.Peny. w exclusively canuaaini with Ilcensed contractors to
construct the Project (Sec. 7044, Business ani Professions Code:) The Conumaxr's U.
cense law dao not appy to an owner of propertywho Wilda or improves thereon.ted,
who contracts fm, such Projects with aconuxur(s) licensed pursuant in the Contrac oas
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License Law.
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WORKERS COMPENSATION DECLARATION
1 hereby affirm and r penalty of perjury oro of the following declarations.
Q I ham and will maintain a Certifies, of Consent in self -mosso fa Worker, Cooper.
sadon. u Provided for by Scotian 3700 of sax Labor Code, fm the perfamanoe of the
work for which this permit is issued.
Q 1 how and will maintain Workers Compensatioe IBmrance, as required by Section
3700 of the labor Cade, for the perfomarrce of the work for which this permit is blued.
'
My Waftes Compensation htsurarlco artier and Policy number am:
Carrier. Policy No.:
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(ThismNon teed not be cempleud time permit Is forooe hundred doRan ($100)
car cot)
I unify that In the pmfomanee of tha Wort for which this permit Is blued. I shall tont
employany person Iraq manner u become sal, to the Werken'Compensation
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Lave, of Califami� •'a
Appli i
NOTICE TO APPLICANT!lf, after making this CerdOoete of Exemption, you should
become subject to the Worsts Compensation provisions of the Labor Code• you must
forthwith comply with such provisions or this permit Nall W deemed owned.
CONSTRUCTION LENDING AGENCY
T hereby affirm out Nem Is a eonswctinn lending agency for the pmfurmancc of
the work for which thin Permit is issued (Sec. 3097. Civ. C.)
Lendeh Name
,
Undoes Addrust
1 certify that I haw mad this application and mu that the show Information Ica
come. l agree to comply with all city and county melanomas and sou laws nlNng to
Wilding construction, and hereby wNauw representatives or this city to comer upon the
show -mentioned property for inspectionu�
(We) agree to saw, indemnify and loopohamless the City of Cupertino against
IiNilitiea,JWgmmu, snsuand wpe" -• which r sty in any way aawe against said Cly
in consequence of the granting of this pemlL
APPLICANT UNDERSTANIPS AND WILL COMPLY WITH ALL N- INT
Issued by: Date
OUTie
SR N5.
1
Re -roofs 4
Type of Roof
rf 'Y
2
Signature n te
HAZARDOUS MATERIALS DISCLOSURE
Will to applicant or future building o.Want mere or handle hasardous material
as dcRnod by the Cupertino Municipal Code. Chapter 9.12. and the NW th and Safcty
Section 25532(a)7
All roofs shall be inspected prior to any roofing material being installed.
QYns IKQNe
If a roof is installed without first obtaining an inspection, I agree to remove
Will tee applicant or future Wilding oaupanl use equipment or dcvlm which
K"humdnus air conuminsms u defined by to Bay Ams Nr Quality Management
all new materials for inspection.
D We,,
QYa (9Nu
1 haw mad the huardoes materials requirements undcrChap m&95 of the Califor.
an Hnslth& Safety Cade. Sections 25505,25533 am125534. 1 undimmed thelr de Wilding
dors not currently have a umarIt. that II'u my responsibility In rmtifY the t of
mqui ichorIrl at u ar,cemnaaaraem y
Signature of Applicant Date
21 °
All roof coverings to be Class "B" or better
Owner of 'gem Do