04020074 (2) CITY OF CUPERTINO �n
BUILDING DIVISION PERMITtCONTRACTORINFQRMA'� N
BUILDING ADDRESS: flog THE WINDOW BROKER PEa""04020074
.WS NAME: PERMIT ISSUE DATE
MAL
PHONE: SANITARY NO. CONTROL NO.
(800) 639-4527
ARC HITECT'ENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
soo LICENSED CONTRACTOR'S DECLARATION Job Description
in C I hemby affirm that I am licensed under provisions of Chapter 9(commencing
<b
with seclude 7f,00)of Division 3 of the Bus Propositions
CodC. dmyI1LCRC lr
e
in o'
afre"' k93gz REPLACEMENT OF WINDOW
jLIZ License s L. LitY.'kk EnnL
^ � Date BAR HITECI'S IDECSLA ION 2 PATIO DOORS �Ltia,ED
z i 1 n rwnJ my plmts shag be toed as pub m meads
AUG;o� Licensed Professional 1 2004
3 OWNER-BUILDER DECLARATION
I hereby affirm thm 1 am exempt from the Contractors License Law for the
po following macer.(Secdun IIA 1.5,Business and Profeedom Cade:Any city or county
9 tai which requires a permit to construct,eller,improve,demol W,or repair any structure
prior in its issuance,also requires the applicant for such permit to rile a signed statement
that he is licensed pursuant to the provisions of On Cmd"efi r"Ucen'c LAW(Chapter 9 Sq. Ft. Floor Area ValuaCCOn950
(commencing with Section 7000)of Division 3 of the Business and Professions Code)or �'L
that he is exempt Therefrom and the hues for the Alleged exemption.My violation of
Secdon7Wl.5 by a,sppiicsinfor.permit subjects the applicann 1.a civil penaltyof APN Number Occupancy Type
not mom than five hundred dollars($500).
❑1,As owner of the property,or my employees with wages As their sale compensation, 32345057 . 00
will do the work and And structure is nod intended or offered fora.].(Sec.7044,Business
and Profession'Code:The CmntraLmes License Law don not apply m in owner of Required Inspections
Property who builds or imposes thereon,and who does such work himself m through his
w
on employees.provided that such improvements arc not intended ordered for sale.IL
however,the building or improvement is sold within one year of completion,the owner-
builder will have the budder,of proving that he did nm build or improve for purpose of
Asia.).
I,as owner of the property,am exclusively contracting with licensed Contractors to
construct the project(Sec.7044.Business end Professions Cade:)The Conuaemr's Lt.
rase law does not apply m an owner of pronany who Wilds or improves thereon,and
who contracts for such pmjecm with a cons ustor(s)lic4nsecipursuant m the Cun=toe3
rove law.
em exempt under Sec. .B h P C for this mason
or Data
WORKER'S COMPENSATION DECLARATION
1 hereby ARnn under perW ry of perjury one of the following doelantions:
1 have and will maintain a Ceroicam of Consent to mif-insum for Worker's Compere
Astion,sa provided for by Section 3700 of the labor Code,for the perli m u ce of On
work for which this Permit is issued.
❑I bare end will maintain Worker's Compensation Insuran¢,as retained by Section
3700 of the LAW,Code,for dm performance of the work for which this permit is issued.
My WorkclrsS C.<(�/InPensatinn lnsupnce caricr dPolicynu then am(s�a..
C...:•./1l C Kn hhgors lots hrnprr .: oTgb Dl�
CERTIFICA7EOF E%EMPnON FROM WpRKERS'
COMPENSATION INSU
Thaseclion need notWcompleted ifthe postO s,mon.hundreddollars(SIM)
or Ices)
1 anify dot in the Performance of the work for which this Permit is issuad,l mall not
employ any person in my manner so as to become svbj.cuo the Workers'Compensotim
Laws of Califmmia.Date
Apulian]
NOTICE TO APPLICANT:If,after making this Ceniriom of Exemption,you mould
become subject m the Worker's Compensation provisions of the labor Code,you most
.,Z foMwith comply wish such provisions or this Permit shall W deemed revoked.
z O CONSTRUCTION LENDING AGENCY
'r. I hereby affirm Nat then is a construction lending agency for On,Performance of
a > the work fur which this permit is issued(Sec.3097,Civ.C.)
lt7 0 Landars Name
ZLenderres
Lenders Adds
U Q 1 certify that l have mad Nis application and mute that the above information is
U. F correct,1 agree to comply with all city and county ordinmues and sou laws relating to
0U building eonswctimn,and hereby authome mprexnuuves of this city to enter upon the
r W above-mentioned propcny for inspection purposes.
LL (We).,me in save,indemnify end keep harmless she City of Cupertino against
FN liabilities,judgmcits,costs and expenses which may in any way.cane against said City
U Z in consequence of the granting of this Permit.
APPLr K4��
ICANr UNDERSTANDS AND W COMPLY WITH ALL NO OINT Issued by: Date
SOURCE RE LA170N5. 3 fes/ r1 —/O
�fX/(� L Re-roofs
atom of n"IcanUConuacmr Data
HAZARDOUS MATERIALS DISCLOSURE Type of Roof
Will she applicant m future Wilding occupanumm or handle lon ur ous material
cfinsd by the Cupertino Municipal Code.Chapter 9.12,and the Health and Safety
de, 0yes �ryS25533(a)? ccu All roofs shall be inspected prior to any roofing material being installed.
❑Yrs
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
mit ha ao nus air contaminants as dcrincd by the Bay Area Air Quality Management all new materials for inspection.
emit
T.��
❑Yes 3 t10
1 have mad the hvasdous materials requimments under Chapter 6.95 of the Caliper,
his Health&Safely Code.Section'255(15,B533 and 25534,1 umlecrend that if the Wilding
does net emocr ly have C Ienan4 B01 it is my reso ntihilily to notify the o:NPNI of Ne
rcquiamentswin mustb nmilm.rty issu sof Cereficase of Occ ry. Signature of Applicant Date
All roof coverings to be Class "B" or better
0 ..,Wmcd.,cm Do¢
CITY OF CUPERTINOEll .,zar. "« �`
BUILDING DIVISION PER xCO TTRACTORAINf&ffie�N-
I h, ..Sf T
BUILDING ADDRESS: THE WINDOW BROKER PERMIT NO.04020074
OWNER'S NAME: PERMIT ISSUE DATE
MALL
IE; SANITARY NO. CONTROL NO.
80639-4527
ARCNITECUENGINEER: BUILDING PERMIT INFO
BLOC ELECT PLUMB MECH
0 0 0 0
u00 LICENSED CONTRACTOR DECLARATION
wE, m Nem n
I hereby affirm 1 lic. d under provisions Of Chapter 9(Commercial
Job Description
_iwish Scotian 7000)of Division 3 of the 11,77
usi d Professions Code, ad my license is
"I9 m infullf ee�derr c (!t� 3�Z REPLACEMENT OF WINDOW
j II z Lice Clas'T Lit
=� Daut BAR HITECTSDEQLA ION 2 PATIO DOORS AUG ( ,
'� �' 1 nrsunJ my plans aha11 he rad u pub¢recarN ) 2004
�yV
301 LimnProfessional swpn
g OWNER-BUILDER DECLARATION BUILDING
'* I ng reason.
.(Tern that 11. exempt from the Contractor's License Law for themy uW lel
UO follwhop requies;a permit n7rUL&Busines and improve.
Co or mrainy cilymccture
m which its isu a permit re anoestrum,alcor,improve,demolish.or repair any structure
FZy pdorwitsiensedI xisto taromm uire lb.applie.cam for such p en's fims,Lte a nWsummem
< (cam incingmdpulsuemwdr,pmviviomnftho orthea simu'anhcnefixal apler9 Sq.Ft. Floor Area Values[ 950
mi-0 that M is exempthhedfromon and of basis n 3for ortheProfessiur
that he u exempt therefrom and Nc buss far the alleged exemption.Any=of
Section 703 LS by any applicant for a permit subjects the applicant to a civil penalty of APN Number Occupancy Type
not mart than Five hundred dollar(8500).
❑I,uownu of(lies property,mmy cmploycuwish wagesu Heir role eompenssllon, 32.3450557 . 00
windo Newark and thestmcturshrumamadcd ororterw mrmic(Scc.7044.1lona ea, Required Inspections
and Profession Code:no Ctomommes Limn Law does not apply to e an owner of q P
property who build&or improves Nemon.and who does such work himself or through his
own employee,provided that such improvements are not intended or offered for sale.If.
however.the building or improvement is mid within am you of completion.the Owner
build.,will lase the hu den of proving that hm did rot build ar improve for pOHwm of
sale.).
1,es owner of the property,am exciusivily contracting with licensed contractors us
nsu err the project(Sec.7044,Business and Profusions Code:)no Contractors LE
n Law does not apply to an owner of Property who Wilds or improves Nemon,and
who contracts for such pmjeets with a contractor(s)licensed pursuant to the Contractor's
Limme law.
❑lam exempt under See .B d:P C for Nis reason
OwnerDate
WORKER'S COMPENSATION DECLARATION
1 hereby af0rm under penalty of perjury arc of the following declarations:
have and will maintain a Certificate,of Carboni to se f-inum for Worker's Compcm
action,as provided for by Section 3700 of the Inbar Code,fm the performance of the
work for which this permit is issued.
❑1 have and will maintain Workers Compensation Insumnec,u required by Scedon
37W of the labor Coda,far Ne performance of the work for which this permit is issued.
My Wmkm'a Ca, penton Insurance carries d Polity nu bar a25.
C1artie/r d f{ (icy No.: oV
,yam cERTIFIC ;OF;U 540N FROM WORKERS'
COMPENSATION INSU
(ThLa mctinn reed not hccomplemd irthe Iernjit¢rr ran.hundred douara($101)
ar less)
I mNfy don in the Performa..of Ne work for which this pormil a issued.I shell not
employ any person in any manner en as to become mbjectto the Workma'Compensator
Laws of California.Dale
Applicam
NOTICE TO APPLICANT:If,after making this Cen ricam of Exemption,you shtwW
became subject to the Workers Compensation provision of theLabor Cada you most
2 foMwho Comply wish such prwuioat ar Nis permil shat[m d.mcd rucked.
zO CONST RUCTION LENDING AGENCY
F-t I hembyaRrm that there is a convection lending agency for the perfufmanec of
LYi> the work for which this permit is issued(Sec.3097,Civ.C.)
W 0 Comes Namc
z Irndcr's Address -
U O 1 certify that I have rad this application and sure Nat the above information is
IIT Fcormt.1 agru to comply with all city and county ordinances and stale laws muting to
building convection,and hereby authodm representatives tar this City to enter upon the
Wmove mentioned propcny for inspection purposes.
(We)agree to save,indemnify and trap hartniest the City of Cupertino against
y liabilities judgments.casts and expcuu which may in any way acmes against said City
in
of tho grouting of
V
APPLICANT eUNDERSTANDS AtND WILL COMPLY WITH ALL NO DINT Issued by: Date
SOURCE RE CATIONS. _
Re-roofs
rum of Apittiam/Canuaemr
HAZARDOUS MATERIALS DISCLOSURE Dam Type of Roof
Will the applicant of future building ocupent nom.,handle mominus material
as defined by the Cupertino Municipal Code.Chapter 9.13,and the Beath and Safety
Code.Section 25532(&)? �a All roofs shall be inspected prior to any roofing material being installed.
Will the applicant or solum building Occupant use equipmatardevices whichIf a roof is installed without first obtaining an inspection,I agree to remove
it havardous air contaminants as dcfncd by the Bay Area Air Quality Management all new materials for inspection.
iahm
❑Yes ¢Nu
1 hue mad the hamudous materials requirements under Chapter 6.95 or the Califon
niarealthkSafctyCode,Setiom M5 5.25533md25534.lunderstsM iftM Wilding
does not currently haat a tenant.that it is my responsibility to Entry de occupant o(Em
requi¢mcmmwhidymuslMmCAPHOrtu issu .or certifiaeor Oca an y. Signature of Applicant Date
E l/O-
� All roof coverings to be Class"B" or better
OG,xr' awhorizC age
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