04110038 (2) CITY OF CUPERTINO ^,
BUILDING DIVISION PERMIT - . CONTRACTOR.INFORMATION _
BUILDING ADDRESS: PERMIT NO.
THE WINDOW BROKER 04110038
NA PERMIT ISSUE DATE
2_385 hfNi20tN_AVS_
E:
SANITARY OL No.
ARCHITECT/ENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
up0 LICENSED CONIRACrOR'S DECLARATION Ib Description
1 hereby affirm that 1 am littnud under provisions Oe$Gn of Chapter 9(commencing p
i Sean ")of Dividon3ofdw I3 nouss pd Professions Code.and my license is
tofu and eff
qi Baseclua I� REPLACE WINDOWS
neo
ARCHI'IE ECLA ION
"Utrsed amen
3 u r Liemsed Prof al
+03 OWNER-BUILDER DECLARATION
<I 1 hereby Affirm Nm I am exempt from the Contractor's License Law for the .
a O following mason.(Scedoo 7(61.5,Business And Prefesdons Codc:My city or county
$ which mquirts A permit to crommucl.ahs,improve,demolish,ncrepair any suocmm
Fax Malo to its issuance.also rtouires tW.applicant for such permit to flea signed statement
£F� Nat he is licensed pcomntlo the provisions of the Conuacmr's License Law(Clupmr9 Sq. FL Floor Area Valua
y $ (commencing with Section 7")of Division 3 of the Business And Professions Code)or
But he u memopl therefrom and me, uts for bthe alleged e5emption Any violation of
Section 7031.5 by any applicam for a permit subjects the applicant to a coil penalty of
not mom n RK hundred dollars(5580). 3 AP�I�I�tt�ber0 0 Occupancy Type
se
1,as owner of the Property,Or my employees with wages as their sol.courpenmllon,
will do the work.and the5uacmm is mat intended Or offered for side(Sax.7044,Business Required Inspections
and Professions
ssions Coda,The Contractorsos m ns License Law dnot apply an owner of Q p
property who buil ds or improves themon,and who does such wort him5el f or through his
ownemployees,provided Nal such improvements are.mintended oroRered forsale.If. '
however Ne building or improvement is sold within m¢year of completion,the awna,
Guilder will law the burden of proving that he did not build or improve for Purpose of
sale.).
0 1.As owner of the property,w madusively contracting with Ikensed conuacfort to
consumer the project(Sec.7044.Business and Professions Code:)The Contractor's Li-
ceme Law does ass apply man comer of property who Wilds or improves thereon,and
who contracts for such projects with a contrvetor(s)licensed pi n ramto be Contractors
LKCOY Law.
❑I;mmoro t under Sse .B&PC for this...
Owner Data
WORKERS COMPENSATION DECLARATION
1 hereby Ali under penally of perjury arc of dm following declaration
1 has and will maintain a Cenificumm Consent maelf-insum for Worker's ComPcm
�i don,as Provided for by Section 3700 of the Labor Code,for the Performaxc of Use
work for which this permit is issued.
I haw and will maintain Worknes Compensation Insufan¢,ss scyuimd by Section
.)700 of NC lsbar Code.(air Ne perform of the work for which this permit is issue.).
My Worker1s1 Co. motion Inwune.eama try no mo�ssber are:
artier. R0. Os^ S. )icy No.:S*l'jL- rX62Ds/'lll
C ICATE OF EX&PTON FROM WORKERS'
COMPENSATION INSURANCE
(Th stegon reodnnt W completed iflW p.rmir is for.hundred dull.(31(10)
or less.)
1 unify Our in the performance of the work for which this permit is issued,l shall nor
employ any person in any manner An As An become subject to the Work.n'Compessalion
Laws of Califomna.Data
Applicant
NOTICE TO APPLICANT.If,after making thu Certificate of Exemption,you should
become subject to Oa,Workei s Compensation provisions of the Labor Codc,you muss
.,O forOwith comply with Such provisions or this permit Shill W deemed revoked.
Z" CONSTRUCTION LENDING AGENCY
'r�+ Ihereby AM.that them is.connructinn l.ndinllq. y for the peffmmermcof
04 the work for which On permit is issued(Sec.3097,Civ.C.)
QLender's Name
.7 z lender's Address
fJ Q I certify Nat I have mad this application and sum not ft alove informatiun is
Fcomett I agme to comply with All city and county ordinances and slam laws relating to
Q U building construction.and hereby RU006M mpresemetiva of Nis city to enter upon Na,
aMvcmemianed property for inspection Purposes
n G (We)agree to save,indemnify and keep harmless the City of Cupertino against
VA liabilities.judgments,Coss Andexpenses which An,in any wry.mise against said City
L)Z to cons.qucrux of the granting of this permit.
ti APPLICANT UNDERSTANDS AND WI L COMPLY WITH ALL NON-POINT Issued by: Date ks Q
SO RC UL 'I—Oso
Re-roofs
Si of AWlicanVCon r Dam
HAZARDOUS MATERIALS DISCLOSURE Type of Roof
W ll dm applicant m future holding asupant Store orhardle hvallous mamdal
a dcfined by the Cupertino Municipal Code,Chapmr 9.12,and the Health and Safety
Code.Semon xs532(,)?
❑Ya tq.l All roofs shall be inspected prior to any roofing material being installed.
If a roof is installed without first obtainingan inspection,I agree to remove
Will Na,applicml or furore building occupant use equipmcm or devices which pe g
7mi,havardovs air contaminants As dcfined by the Bay Area Air Quality Management all new materials for inspection.
? ��❑Yes QN.
I have read Ne hvardms matedds mquimmcs underChapter6.95ofthc Califon
HcalN&SafctyCodc,Sections 25505,25537 and25534.1 undersand thalifthe Wilding
es not currently haw a tenant bur it u my responsibility u notify Ne occupant of Ne
mm hich mus elpdortoiss reofa Ccruhcam of(kcupancy.mSignature of Applicant Date
w harimdagcni m All roof coverings to be Class "B"or better