04070011 (2) CITY OF CUPERTINO " ar
PERMIT ^M.'�Aw�cTI/ Nd'BUILDING DIVISION OsTi -
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BUILDINGADDRESS: GREATER BAY CONSTRUCTION PERMIT"°04070011
OWNER'S NAME: PERMIT ISSUE DATE
AM GB ESTATE
E: HOMES qUTTR 2no
SANITARY 9 CONTROL N0.
(408) 248-6600
ARCHITEC(ENGINEER: BUILDING PERMIT INFO
BLDG ELECT' PLUMB MECH
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X00 LICENSED CONTRACTOR'S DECLARATION lob Description
U I b affirm that I am licensed under provisions of Chapter 9(commencing P
with Sc 7(Nll)of Divlalon 3 of Na Easy and Professions Coda.md my license is
. � immflf emcleffact. REVISION--TRUSS FRAME
Lmenc Claw Le.g
^� Date cantm�etgr NO NEW PERMIT ISSUED/ORIG. #03110115
,e ARCHITECT9DECI.ARATION
y I understand my plana shall W used as public records
DIIU
;Q Licensed Professional
OWNER-BUILDER DECLARATION
iI I hereby affirm the,I em emmpt from du Conuamers License Law for,he
O O following mason.(Section 703 1.5,Business and Professions Code:Any city or county
which requires a permit,o construct,alter,improve,demolish,or repair any suumum
F prior us its issuance.also requires the applicant for such Permit rile a signed statement
�O mu he is licensed pursuanumhe provisions of the Contractors License Law(Chapter 9 Sq.Ft.Floor Area Val uatio�115
z❑ (commencing with Section 700(h of Division 3 of me Business and Professions Code)ser
3 g that he 0 exempt therefrom and the basis for are alleged caempdon.Any violation of
Section 7031.5 by any applicant for b permit subjects the applicant,...ivll penalty of APN Number Occupancy Try( e -
not momthan firohundred dollars(5500). P Y ']P
❑I,as owner cribs property,or my employees with wage u their sale compensation. 35922076 . 00
willdo outwork.and theswc,um is not intended orriffm d partial,Isom.7044,Business
and Professlau Caeca:The C.mmcmra License Law does not appy m an awns,of Required Inspections
property who builds or improves thereon,and who does such work himself or through his
awn employees,provided that such improvements ere not intended oroRemd for sale.It,
however,the building or improvement is sold within one year of eampledon,me owner
builder will have the burden of proving that he did not Wild or improve for purpose of
al,.,. C�aS
[SJru owner of the propcng.B exclusively and Conaacting with:ittno Contractors
to
wet the es not (Sec.too4C,Business and Professions Cade:)The Convector's d
cense law dura not apply a is owner of pmpeny who Wilda or improv Neuron and
who.Lacca forauch projects with a c nvmtaKal liaised punwm m the contractor's \
Leense law. ,rv\
❑ camp, ,B&P C for is n
Owner Oau AL
WORK 'S C PENSAGON DECLARATION
1 hereby afflux un r ty of perjury oro of the following dec dose:
have and will maintain a Certificate of Conserv m self-imam for Warkcrs Cempcm
on,as provided for by Section 3700 of Ne labor Code.for the parformatue of,he
work for which this permit is Issued.
❑I bare and will maintain Worker's Compensation Inwranec.as required by Section
3700 of the labor Cad,,for Ne performance of the work for which this Permit is issued.
My Workers Compensation Insurance ce,fiar and Policy number am:
Qartjgs: M Polity FROM
r
V✓/
CERTIFICATEOMPE SATIONONFRAN WORKERS'
COMPENSATION INSURANCE ,
obis section wed not becampleled trust permit is intone hundred dollars(SIM)
orless.)
1 certify that in the performance of the work for which this permit Is issued,l shell not
employ any person in any manes as to become subject o the WoftW Compensation
Laws of Califomie.Data
Applicant
NOTICE TO APPLICANT:If,after making this Campcata of Eacmption,you should
become subject to the Worker's Compensation previsions of the labor Code,you must
.J forthwith comply with such provisions or Nis Permit shall W dccmcd tevoktd.
Z """ CONSTRUCTION LENDING AGENCY
'r+^ I hereby affirm Net Nate is a construction lending agency for Um performaee of
�i the work for which this permit is issued(Sec.3097,Civ.Cd
W� Q Lenders Name
7 Z larders Add.
V Q I certify that I have read N.aPplicatleo and sate that m,move informnlom is '
Iy Fcorrect. m emct.1 agree comply with all city ad county ordinances and sou laws misting to
O V building construction.and hereby authorim mpreunmtives of this city to enter upon the
W m(tw-mtminned property for inspection purposes.
G (We)agree in an.indemnify and keep harmless the city of Cupenim against
h liabilities,judgments,costs and expemu which may in any my merit againsl said City
t),Z, in consequence ofma granting of ibis permit.
�-' APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NO -PO NT Issued by: Dat
SOURCE REGULATIONS. t
2 Re-roofs lif
gnamm of ApplU RDOUS MATERIALS DISCLOSURE 1D.11Type of Roof
H
will the murfuture building occupant itom or handle ho ous material
as defined by the Cupertino Municipal Code,Chapter 9.12,and Ne Health and Safety
ode. rly.25332(a)7 All roofs shall be inspected prior to any roofing material being installed.
❑Yu ._ �Y
Will the applicant or future building occupant use equipmentordevices which If a roof is installed without first obtaining an inspection,I agree to remove
hazardous air contaminants w defined by the Bay Arta Air Quality Management all new materials for Inspection.
,ricR 1111
❑Yes u
I haus mad the haamicus mammals requirements under Chapter 6.95 of the Caliber.
ria Health Ssfcty Cale Stctions 25fi3,2553J aJ 2553a.I unJcrsmnd wif Wilding
Joan nod rcn0y bows a dost Na,it u my responsihildy m nohuy mese ant of m
rcyui c h mus,ome,pimmissua<cofaCc0ljcatcof. ,a a Signature of Applicant Date
Owner or cam nmd t 7 � Dam All roof coverings to be Class "B"or better