05110125 CITY OF CUPERTINO ��uz
BUILDING DIVISION PERMITCONTRACTRII (�?]�TIQN,
`y= ��Dww;n�£
BUILDING ADDRESS: P0...rNO.0511012 5
8665 LOREF, AVEPE MIT LSSUBDATfl
0 ER'S NAME:
04/11 /2006
PRUNE: SANITARY NO. CONTROL NO,
ARCHITECrIENGINEER: BUILDING PERMIT INFO
BO EO PLO O
i Wp LICENSED CONTRACTOR'S DECLARATION lob Description
U FFy I hereby.Hunt that I am licensed under provisions of Chapter 9(commencing
S wM Ba d..70W)of Division]of the Business and 1`1011OWuns Coda,Me my licenseis
N infull ram amaffect. ADD 486 ' -LIVING/BEDRM/BATHRM-450 ' GARAGE
License Chase Lte'g REPLACE (E) ROOF-ADD SKYLIGHTS-CONVERT (E) GARA
F Dom TSCOADECLARATION ARCHITECTS W.a DECLARATION TO LIVING SPACE-SANITARY COVERED BY SANITARY
jy I undcuunJ my plana shell W met u PuM1lk marth
cep Licenced professional
`N Oat I am aUIIDER mDECLARATION
a I hereby.(firm(Section n I em ucmpt from tbo Convectors License law far the
`p o following moan. grala TOBIS,Business and w,de lou Code:My city or county
5$vt which requires a issuance,s hit m quires the aimn immnw,daermit t li a minor any ned un enure
prior mia ted Forwent
as ms the f Consuch parmtlmfrkaeLaw(Catcment Valuation
< (CoMiscingwitPurmann mIW of Division
ofthe Businessand Proelaw(Chapin 9 Sq.Ft. Floor Area
that heismgm, Secdospeand of basis
ofr theaeged essandon.Any
Code)or $129554
that io is exempt anrtfrom and the bur it the Nailed PPIwmI in Any violation of
Section Was l ve gry applicant for permit subjects the applicant m a civil penalty of APN Number Occupancy Type
not mart tun Ow hundred dollars(5500).
Q I,u owner ofthe property,army=ploy=with wiles u thdrsam compensation, 37 5
will W thcm Is.,nw
work,Md mcgrucuwt idedarolfered mrsam(Scm. ,BusiM•• - Required Inspections
Md Professions Codehe TCenuamors License taw dem,not apply m an awns a q P
property who buildso,improv deacon,and whodocamchwarl,himmlfor Wough his
awn employers,provided that such impogammta are rot intended wagered(oral,If.
however.the building or Improvement is sold within all year of eempledan.the Mass-
builder
aenbuilder will have the burden of proving that he did not build or Improve for purpa a of
sale.).
Til 1.n owner of the Property,am exclusively camas gni with Ilceued amm
nuere
Folheuixt the pmjea(Ser.7094,Business W Professions Code:)The Commune'U-
can law does sot apply to an owns of propenY who Will ar improv themon.and,
who contra for such Projects with a antactora)licensed puraunt to the Contractors
License taw.
❑I am exempt under See. .6 k P C for rcamn
One // O
COMPENSArIODECLARATION
1 thereby
affirm under penalty of perjury nu of the fallowing den aiddons
Ihaw orad wilimainainaCWBcem o(Consemroself-Inwmfw Wortrra Compan•
union,u providrA for by Sedan 77.0 of the Labor Code,for the performance of doe
work for which this pamil is Wuc6
[]I lave and will maintain Warlmes Compensation Insurance.as mquimd by Sedan
1700 of me Labor Code,for Ne performance of the work for which this permit is Wed.
My Workers Compensation Insurance carrier and Policy number art:
CMIc, Policy No.:
CERTIFICATE OF EXEMPTION FROM WORKERS
COMPENSATION INSURANCE y
(This section aced at W completed lfam permit is founachundrtddMam(5100)
or leas)
1 certifv that in the performance of the work for which this Permit is issued.)Nall not
employ any Perron in my amencrm 7tolfa orvbjtttxtW Wartrn'CampensWan
Laws of Califorry.vn�W W
NOTICE
ani PPUCAN
NOTICE TO APPLICANT.If,Corr making this CenlDate of Labor
you ushould
a=
boeomeh comp m wit Worker's Companstan Permit
Mai of the Labor Coda you mtW
.JO forthwith comply with each provisions Or this permit Nilbodeemed mwtrd.
z Try. CONSTRUCTION LENDING AGENCY
[--t Iarce,. .der dereua construction lending agency for the Performance of
Ix> tie work for which this permit is issued(Sea.3(D7,Cih,C.)
W�C1 Leaders Name
z Lenders Addmse
t.p Q 1 codify that I have read this application and sum was Ne above information Is
F cancel.I agree in comply with all city Md county ordinances and alae laws relating m
OU building construction,and Wroby authorize representatives of this city to enter upon to
Uabove-mentioned property for impaction purposes.
(Wo)agree to an.indemnify and keep harmlua the City of Cupertino against
IA Iiabilides,judgmenu.cnsu aed expenses which may In my way amus siainsl said City
V in consequence of the grunting of this Pat
a APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT Issued by: Date
S�T ONS.
fC��r�R�i Re-roofs /`--
Signtureof ppliceruContacter Dam
HAZARDOUS MATERIALS DISCLOSURE Type of Roof
Will de application or future building acevpantaerc orhsndle haardom materiai
as defined by six Cupertino Municipal Cade,Chapter 9.13,and the Health and Safety
.
Section 25552(a)7 All roofs shall be inspected prior to any roofing material being installed.
[3y" I.
`ure If a roof is installed without first obtaining an inspection,I agree to remove
Will the applicant or ffutbuilding occupmt sax mulPmom or devices which
emit hazardous air mnmminanu as dc0acd by the Bay Am Air Quality Management all new materials for inspection.
District?
❑Yes XNu
I haw mad the hvardous materisis rcqu lrcmcnu under Chmmr 6.95 of the Cal ifw-
niaHes W 95a(cty Coda Smdau25505.25515 and 25534.1 understand thatifthc building
does not c ty haw teem,that it b any m mawlbility as nodfy tin occupant of the
Dom'