02090191 (2) CITY OF CUPERTINO ,a. ^' + '°"' *•' R'"a'"
BUILDING DIVISION PERMIT •CONTRACTOR INFORMATION:
BUILptylgkyl9ES9UDY AVE . STANLEY CONSTRUCTION PERMITNO2090191
CHAEL & LISA WARREN 852 JORDAN AVE APPLICATOI�I/BY®T92O02
PHONE: (650) 969-1962 SANITARY NO.// // CONTROL NO.
ARCHITECT/ENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
r00 LICENSED CONTRACTOR'S DECLARATION ?I p
zu_f- Iion7Y)firmthatIamlicensed under provisions ofChapter 9(commencing REMOVE EXISTIISI�b990'ig"PRUCTURE
�•tjwithSectionRuce]IXXOec Division 3 o NC Business anJProfessions Code.and mylicense is
r License Clam,d effort.
OZ—
Date
Class Lier
asuar
F=1㤠Dau CroTSDECLARATION
££ ARCHITECTS DECLARATION
K j I undersand my plans shall be used as public records
�pu
s-u At Licensed Professional
OWNER.BUILDER DECLARATION
ay<m I hereby affirm that I am exempt fru.the Conuactnrs License Law for the $5000
la a 0O following reason.(Section 7031.5.Business and and Professions Code:Any city or county
$� which requires a permit to construct,alter,improve,demolish,or repair any structure
prior to int issuance,also mquires the applicant for such permiuu file a signed statement
�44�<
that he is licensed pursuant to the previsions of Nc Contractor's License Law(Chapter 9 3Sg51IIffik+b&AI@m Valuation
(cnmmencingwiNS ctinn7")(ifDivision3ofthe Businessand Pfofcuions Code)nr
.. that M is exempt Ncmrrom and the basis for the alleged exemption.Any violation of
Section 7031.5 by any applicant for a permit moccO the opplicanrto a civil penalty of
not more Nan fiva hundred dollars(S500). A Occupancy Type
❑I,uowner of she pmpcny,or my employee with wagesu their axle compensation,
will do the work,and the someone is not intended oroffered for sale(Sec.7014,Business
and Professions Code:The Condructor's License Lew docs or apply lf an owner of Required Inspections -
propcny who builds vi improves thereon,and who are
in e work himselfedNmugh his
ownemployees,ping or
that such impmsemenuarenot ear of
completion,
for matter
however the Wilding or improvement is sold within one year of completion,Ne owner
builder will hive the burden of proving Net be did not Wild or improve for PurPou of
talc.).
6 1,as owner of the property,am exclusively contracting with licensed comemoss to
construct the project(Sec 7044,Business and Professions Code:)The Contractors Li.
cense Law arcs not apply to an owner of property who Wilda or improves themon,and
who mulcts to" h projects with a monam,ft)licensed porsuanuo the Contractors
c se Law.
am c¢mps under Sec. 7� B&P C for this moon
Dat o
WO COM SATION DEC ION
I hereby aNrm under penalty of perjury one0 following declarations:
❑I have and will maintain a Cenificale of Consent wir-insure for Worker's Compen-
aation,u provided for by Section 3]W of the Labor Coe.for the performance of the
work for which this permit is issued.
❑ I have and will maintain Worker's Compensation Insurance.as required by Section
370E of the labor Code,for the performance of the work for which this permit is issued.
My Worker's Compensation Insurance carer and Policy number sur:
Carrier: Policy No.:
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(This section need not be completed if the permit is forme hundred dollars($IN))
Ices.)
I certify Nat in the pnearrmy�ry��aen�ce of the work for which this Permit is issued,I staff not
employ any person irrarytm`er nu to become subject the Workeri Compensation
Lawsof Celifomia.WCc Se 4 jQO,Z
TO
p icunl _4w. /V ,
a
ICE APPLICAsn'.If,after making Nis Cer ilic4te of Exemption,you should
crime subject Into,Worker's Compensation provisions of the La Wr Cale,you must
OO forthwithcomply with such Provisions or Nis Termitshall he deemed revoked.
� .~N. CONSTRUCTION LENDING AGENCY
1 hereby alarm that there is a construction lending agency for the performance of
a, work for which this permit is issued(Sec.3097,Cie C.) as
W� Le Lender's Name
� ,z Lender's Atltlmss
V O 1 certify Nat 1 have read this application and sum that the above inhrnnatiun is
(•-' coned.I agree 10 comply with all city and county committees and sate laws relaring to
Q U Wilding construction,and hereby authorise repterenutives of Nis city to enter upon the
ITa ahovomemomed property for inspection purposes.
(We)agree m save,indemnify and keep countries the City of Cupcnimo against
jl liabilities,judgments,corm and expenxs which may in any way accom against said City � J
in
of
his
V APPLICANT UNDEuicum,of the RSTANDStAND WILL COMPLY WITH ALL NON-POINT Issued by: Date
SOURCE E ULATION .
0 Re-roofs
at fApplic Contractor
HAZARDOUS MATERIALS DISCLOSURE Type of Roof
Will the applicant or future building dmcupatn store or handle haxrdous material
fined by the Cupertino)Municipal Code,Chapter 9.12,and the Health and Safety
c,
SO
255]2(¢)7
❑Yes VIN. All roofs shall be inspected prior to any roofing material being installed.
Will the applicant or7future building cecupam use equipment or devices which If a roof is installed without first obtaining an inspection, I agree to remove
emit hazardous air contaminants u defined by the Bay Area Air Quality Management all new materials for inspection.
District'? ,,,///
C]Yes Dori
I have read the hazardous materials requirements under Chapter 6.95 of the Califon `
ria Health&Safely Code,Stttiom 25515,25533 and 25534.1 undersand flm if the building
does Wt touchily have a tenon,Nat it is my resNuvibility m notify t aeupant of Use
requirements which must met prior to issuance of a Cenif¢am Bf Occ an Signature of Applicant Date
wrier amhudze agent - Dam All roof coverings to be Class"B" or better