04040097 (2) CITY OF CUPERTINO ��itr+Tr+�♦���l,�<p'` ��»1"�+ 'p�g�� "ri2
BUILDING DIVISION PGRNUT '.ro CoaY•+ RAIPITVl�1111`ORMATION
BUILDING ADDRESS: CUPERTINO CONSTRUCTION INC PERMIT"'04040097
OWNER'S NAME: PERMIT ISSUE DATE
DANNY
E; SANITARY O. CONTROL N0.
ARCHITECT/ENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
uo0 LICENSED CONTRACTOR'S DECLARATION
<� I hereby affirm tun I am limnxd under provisions of Chapter 9(commencing Job Description
with Section 7")of Division 3 of Ne Business said Professions Code,and my license is
o mfull and ukcc�3
LicensoCiarse Clnz Lk. u�e9rf SFDWL-2 STORY/LIVING
M A
Dam Con ter GARAGE 400 SQ. FT n
. '�V�
qq ARCHITECTS DECLARATION
3� 1 understand my plans hall W used u public records A
CLimn Pmfcssional /yU/5
5
OWNER-BUILDERexempt from
Ce CelamON C77
n 0 I hereby affirm o n I am eBusin from the Canton Co c:Any c Law for to
p 0 which
reason.(Sadat T(B LS,Buahm.sim r w,demob Cmlc:repair
y cur county o0
K$ which reyuirem a permit re uirea t e alter,improv,hitermeh,fie pair any ummure
't—re that hesiulssated palsumyo thovisiosofcant for a ontradmiuoicense ned aw(utemem
f?C thatmis eccmncd(Section to Be,the provisions of the Convector and Professional,
roflaw(Cuarxr9 Sq. Ft. Floor Area { 'p ValW 000
1or 1 (commencing he
ingwithherefrn]o00)the
basis far
the
caped cuaantl Prof un,varide)ant
or
of F, Y
i $ Not W u exmpt thcxftem and dlo bust for the alleged csemption.Any violation of c
Section 7031.5 by any applicant for a permit Subjects the,applicant to a civil penalty of APN Number _ lrS OCCU ane T
not marc an five hundred doluss($50y. t.. P Y Type
Lasowncrof the ft Unde,or mYemntendea wituwagnuthev axle compensation,
32650031 . 00
will deNewark and ft he Con ranot intendede aw t for ina(Sec.70M.owner
and property
whiotu code:The improves
teams Liaise law does not appy ff m owner of Required Inspections
..acro whobuildsofimproverchinaarand who sow sin such work himxlfedthrough his
awn employees,provided orithis such improvements art not easofc mpletired for owner,
haven(,the buildingft orimprovc retia BOBidnot yeti ofcompletion. of
buildtt will Nn the WNcn of proving at W did not build or improve for prepare of
sok.).
❑1,as owner of the progeny,am exduaively contrecting with licensed contractors to
convect the project(Sec.7044,Business and Professions Code:)The Contractor's Li
corse law docs not apply to an no,of property who Wilda or improv f...and
who mnwcu for such projects wits a eontnenuhl)licensed p.am,to the Conwetor's _
Licenx law.
❑1 ant exempt under Sec. .B At P C for this reason
Owner -'72�--_ Date
WORKER'S COMPENS ON DECLARATION
I W m reby afruuntie(penalty of perjury aro of the following declarations:
ase and will maintain a Cenifcaus of Consent m xlfinsure for Worker's Compo(
cation.as provided for by Section 37M of rue labor Code.for the performance of dtc
work for which this permft is issued.
❑1 have and will maintain Worker's Compcnadon Inxnnec,as required by Section
3700 of the labor Code,for the performance of the work for which this permit is issued
My Work�rr`Y3 Compensation Inaunnce carrier and Policy number am:
canner. Policy No.:
2�Ap 5.n u
51FI CATEOF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(This section need not or completed if the permit is rmonc hundred dollars(Sla)
lir mos.)
1 certify the in the pcsfprm rose of the work for which this pemtit is issued.I shall not
employ any person in any manner an as n Wcome subject to tW Workcm'Compensation
laws of California.Date
Applicant
NOTICE TO APPLICANT:If,after making this Cenirimm of Esc rium,you should
Wcome subject to the Worker's Compensation provisions of the Labor Code,you must
�2, rorNwiN comply with such provisions or Nu pcmtit shall W decnncd rewkcd.
z CONSTRUCTION LENDING AGENCY
'carr I hereby affirm that Nen is a construction lending agency for the performance of
(lei tW work for which this permit is issued(Sec 3097,Civ.C.)
QLender's Nan.
Z Lender's Address
J Q 1 mAify that 1 Nn mad Nis application and sum that the above information is -
correct.1 agree to comply with all city and county ordinances and mute laws relating to
0 V building Construction.and hereby authDrim representatives of this city to color upon the
r [k7 move-mentioned intercity for inspection purposes. `
(We)agree to saw,indemnify and keep hvmss the leCity of Cupertinoaga
ino inst !
F`h liabilities.judgments.mmut and apenneewhich may inmywayacmcagatim,sold City �j-
t.7 ? in APPLIcor Bic Of I
C NTUNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT Issued by: Date
SOURCE REGULATIONS. (4
��.--•1 —� Re-roofs
Signature of Applican✓Contractor Date
HAZARDOUS MATERI DISCLOSURE Type of Roof '
Will tW applicant or future building occupant atom or handle hazardous..mist
as dcrrncd by the Cupertino Municipal Cade.Chapter 9.11,and the Health and Safety
Code.Section 25532(a)?
El Yes XNo All roofs shall be inspected prior to any roofing material being installed.
Will the applicant or future building occupant use equipment or devices which If a roof is installed without first obtaining an inspection,I agree to remove
harardous air conmminans as defined by the Bay Area Air Quality Management all new materials for inspection.
uicR
C]Y. /p No
I have read the harallousmaterials requirements under ClupuO6.95 of the Calirm.
ria Health&Safely Cade.Sections 15505,15533 and 25534.1 undersand thmifthe Wilding
deem not currently hast a Imam,that it is my responsibility to notify the Occupant of Inc
requirements which mumbo or missuana cur, nifiemu of Omdpdmy. Signature of Applicant Date
Owner of acmmived agent `� Dam All roof coverings to be Class"B" or better