03070063 (2) CITY OF CUPERTINO "�
BUILDING DIVISION PERMIT CONTRACTQR IN 'OILMATION
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BUILDING ADDRESS: "'"""03070063
ERMIT N00 3 0 7 0 0 6 3
OWNER'S NAME: PBRMIT ISSUE DATE
MICHELLE LIN
NE: SANITARY NO. 2 CONTROLNO.
ARCHITEC(ENGINEER: BUILDING PERMMiNFO
BO EO PLO O
306 LICENSED CONTRACTOR'S DECLARATION
4 F 1 hereby affirm that I am liwnsed under previsions of Chapter 9(commencing lob Description
with Section]011lB of Division 3ofthe BuglneM dPrefusions Cole,end�r ylicenw is
m00mme C 5� /f 1S DEMO OF SWIMMING POOL
H Z Lice, CI c.N
4 Dam ® CanrecmrCONTRACTOR: DISTINCTIVE LANDSCAPES, INC.
n=£�
A ON
ARCHITELTSD ,
k u I understand my plans shall be used as public records
a
s G� Licensed Professional
'0 OWNER-BUILDER DECLARATION
<S 1 hereby affirm that I am exempt from the Contractor's License Law for the
eO following mason.(Section 7031.5,Business and Profsssiom Code:Any City or county
m which requires a permit to construct,alter,improve,demolish,or repair any structure
9i poor In its issuance,also requires the applicant for such permit to ri le a signed statement
pY< mat he is licensed pursuant to the previsions(if the Contractor's License Law(Chapter 9 Sq. Ft. Floor Area Valuat"800
yF� (commencing with Section]WO)of Division]of the Business and Profession Code)it
sy that he is exempt therefrom and 0te basis for Ne alleged exemption.Any violation of
Section]031.5 by any applicant for a permit ubjects me applicant to a civil penally of 3 9&N441"crO 0 Occupancy Type
not mom man five hundred dallies($500).
El 1,as owner of the property,or my employees with wages as their sole compensation,
will do the work and the structure is not intended or offered fomale(S.C.7044,Business Required Inspections
and Professions Cods:The Conuactora License,Law docs not apply to ns an owner of ']O4 — DEMO q p
propenywho builds orimpro m dNercon,and whodoessuch work himselfor through his
own employees,provided thatsuch improvements ve not intended or offered for sale.If,
however,Ne building or improvement is sold within one year of completion,me owner.
builder will have the burden of proving Net he did not Wild or improve for purpo¢of -
aide.).
❑I.as owner of Ne property,am exclusively contracting with licensed contractors to
construct the project(Sec.9044,Business and Professions Cade)The Contractor's LL
come Law does not apply to an owner of property who builds or improves themon.and,
who contracts for such projects with a contracmr(s)licensed pursuant to the Contractor's
License Law. - -,
l am exempt undo,Stu. B A P C for this reason
Owner Data
WORKERS COMPENSATION DECLARATION
1 hereby affirm under penalty of perjury one of the following declarations:
I haw and will maintain aCcnificom of Consent to aelGinaum for workers Compsm
1037�00
ion,as provided for by Section 37011 of the labor Code,for the performance of the P
,I
rk for which this permit is issued. "� J
I have and will maintain Worker's Compensation Insurance,as required by Section
of the labor Code,for un psrfarmence of the wort for which thp pe�CE i sued.
tare Comp nsaOan lnsunnm ca vier and Policy number.X.F S�sJe h.,d P )Ub/a7-o��
CERTIFICATE OF EXEMPPI OM WORKERS'
COMPENSATION INSURANCE
(This eectinn iced not he completed if the permit la fnrone hundred dollar(5100)
or Ices.)
1 Gentry Nat in the performance of the work(or which this permit is issued.I shall not
employ any person in any mannerse as W become subject to be WaTla ri Compensation
Law s of California.Data
AFPlieam
NOTICE TO APPLICANT:IL after making this Ccnificate of E¢mplion,you should
become Subject to the Worker's Compensation provisions of the labor Code,you must
.JO forthwith comply with such provisions in his Permit Mail be deemed revoked.
z' 55CONSfRUCnON LENDING AGENCY
(-t I hereby affirm Net Man is a construction lending agency In,the performance of
s7 the work for which this permit Is issued(Sec.3097,Co,C.)
W�~n. Lenders Name
U, builder's contest V
U Q 1 certify that 1 have mad this application and cam that the show information is
174 F correct.1 agree to comply with all city and county ordinances and sum laws relating to
V above
-mentioned
hembyamhoprposes atives of this city to enter upon the
W ahova.(We) nc0 properly fininspection nifakeep harmless
a
fy (We)agree Io cove,indemnifyandhich hay in
the City of Cupertino against
s.tN incan.....ofhecostsang expenseswhichmayin anyway accmc egaimtcoidCary
V t.
APPL CANTeUNDERSTIANDSthis
AND WILL COMPLY WITH ALL NON-POINT Issued by: Da
SOURC GUL TI N
71716 Re-roofs
netts fApplimnVConlncla' Date
HAZARDOUS MATERIALS DISCLOSURE Type of Roof
Will the applicant ser future building uccupam store or handle hmafdeus material
m derined by this Cupertino Municipal Code,Chapter 9.12,and the Health and Safety
Code,Section 25532(.)? /alu All roofs shall be inspected prior to any roofing material being installed.
❑Yu l�
Will the applicant of future building ove.pam vac equipment or devices which If a roof is installed without first obtaining an inspection,I agree to remove
It ha'rardnus air con mil. defined by Nc Bay Ama Air Quality Managcmcnt all new materials for inspection.
istricli
Oyu
Nn
(have mad Neh mrdnoamearialsmquimmenmunder Chapwr6.95ofthc Califor.
nia Hea1N ffi SafetyGode.Secuons25505,25533 and 25534.1 undersand thatif thc building
does not currently haw a Tenant.that it is my responsibility m no de wcupant of the
requinmcna wh'chmusl poor W issuan ifs Certificate ni u ;y/ Signature of Applicant Date
or aumurirsd.gem Date D All roof coverings to be Class "B" or better
,
CITY OF CUPERTINO DEMO D 3 07L o ��
CUPERTINO PERMIT APPLICATION FORM
APN# Date: E
Building Address:
a/ 111A W. V
Owner's Narlaea /A�� 1� ��/• ]��#
ContractLicense#:
s4�t^Gf7b�i sd s He . 77> 7/a,K
Contact: Phone#:
,Gk d, A444+4- 4/0 -mak -9, 16
Alicant/Cont ctor:
G�/n
Buildin erntit Info:
Bld Elect Plumb Mech
ob Description:
Residential: 4:-hA J Commercial:
Sq.Ft. Floor Area: $/Sq.Ft.:
Architect/Engineer: Valuation:
Type of Construction: Occupancy Gr up:
Qty. if
AppQgablFee ID Fee Description Fee Group
BPERMFEE Bldg Permit Fees BUILIDNG
BSEISMICOM Seismic Commercial BUILIDNG
BSEISMICRE Seismic Residential BUILIDNG
BPLANCHK Plan Check Fee BUILIDNG
BUSLIC Business License BUILIDNG
2 ,L �3 6
�37 �'