04050153 (2) CITY OF CUPERTINO �' ^ '"` y £";
BUILDING DIVISION PERMIT CU1�fiTRACTUR'�NF1�ItM`�ATIOIV
'
BUILDING ADDRESS: GREATER BAY CONSTRUCTION PERMrr"°04050153
OWNER'S NAME: PERMIT ISSUE DATE
GB ESTATE HOMS
E: SANITARY NO. CONTROL NO.
408) 248-6600
ARCHITECT/ENGINEER: BUPERMIT INF
BLDG ELECTLECT O
PLUMB MECH
O o LICENSED CONTRACTOR'S DECLARATION
I hereby affirm that I am licensed under provisions of Chapter 9(commencing Job Description
with Section 701X1)of Division 3 of Ne Business and rectifications Code,and my license is
4 � immlfarecaill REVISION--IN HOUSE USE ONLY
j Z License ClassLic.R
Contractor NO NEW PERMIT ISSUED ORIG. #03110114
✓� ARCHITECTS DECLARATION
cy3 1 unticraunJ my plana shell he used u public mcnNa
38t;a Licensed Professional
OWNER-BUILDER DECLARATION
F I hcrcby athero Nal 1 am exempt from Ne Contractor's License Lew far the
e O following mason.(Seed.703 1.5.Business end Professions Code:Any city or county
which require a permit to constme t.ellen Improve,demolish,or repair any structure
prior to its issuance.else requires the applicant(orsuch permit to Glc a signed statement
HaO thatheislicensedpursuantmNeprevisionsofNeContractor'sLicenulaw(Charter9 Sq,Ft.Floor Area Valuatio,$107
y+ (commencing with Sealed 7000).(Division 3.10.Business and Profusions Cnde)or I
y that he is exempt therefrom and Bee basis for the alleged exemption.My violation of
Section 7031.5 by arty applicant for permh subjects the applicant to a civil penalty of APN Number Occupancy Type
not mom Nan five hundred dollars(55(10). 3 5 9 2 2 0 7 5 0 0-
❑1,as owner of ibe pmp ray,or my cmploycu wlN wage u Noir wle eompenaelion,
will do thework,end Ne swnurc is not intended oroRered Tarsale(Sec.7044,Business -
and Pothooas Code:The Contractor's License Law it=not apply to an owner of Required Inspections
property who bui Ids or improves Nemon.and who dos such work himself or through hisown -
how employees,provided that such imps old within
ne you ded ofcom oRemd the owner. ,a.v
however.the avbuilding, or den of moving
old within ale yeas of completion,Po owned
builder will have Ne burden of proving Nal he did nal Wild ar improve for purpose of
ram.).
es ower of Ne properly,am exclusively confessions Code:)Th.
Contractors i. \
wct
"here
(See.7044,Business and Profusions Code:)The licensedcontractors
to
rue Law does not apply to an owner of property who Wilda or improves Beeman.and
who contracts for such projects with acomrutaKs)licensed pursuant to the Corma does
License Law.
❑1 am exempt under S ,B k P C f r this season
Ownu Dau — 2
WOR COMPENSATION DECLARATION
I hereby affmn under Penally of perjury one of the following declarations:
I have and will maintain a Candfic on Consent to elf-insum for Werkels Compen.
gait..,as provided for by Seclian 3700 of Bee labor Cade,far the perfarmeno of the
work for which this permit is issued.
❑I ban and will maintain Worker's Compensation Insurance,at,required by Secure
3700 of the labor Code,for the performance of the work for which this Ismail Is banned.
My Workefs Compensation Insurance carrier and Polity number art:
Cartier. Policy Na.:
CERTIFICATE OF EREMMON FROM WORKERS'
COMPENSATION INSURANCE
(This section need otbecomp:ered if the permit is foron,hundred dollars(SIM)
or less.)
1 certify that in to performance of the work for which this Permit I.!..it.I shell at
employ any person in any manner so as to become subject to the Workers'Compensation
Laws of California.Data
Applicant
NOTICE TO APPLICANT:IL after making this Cerificate of Exemption,you should
become subject to the Worker's Compensation provisions of the Labor Cade,you must
,QO foMwith comply with such provisions or this Permit shall W deemed invoked.
E(7 CONSTRUCTION LENDING AGENCY
rry IWrcby affom that Nem is a construction lending agency for the Performance of
Qidte work for which thin permit is issued(So.3041.Civ.C.)
QLender.Name
Z
U Lender's Address
V Q I certify Nn 1 have read this application and sum that the above information is
{1w F coned 1 agree to comply with all city and county ordinances and state laws refiling to
Qbuilding construction.and hereby authorize representatives of this city to enter upon me
0.UWi above-mentiuned property for inspection purposes.
(We)agree to on,indemnify and keep harmleas the City of Cupertino against
n Hebrides.judgments,costs and expenses which may in any way accrue against said City
V rZs APPLICANTeUNBec STA geSIAND WILL COMPLY WI H AL NON-POINT Issued by: Date
SOURCE REGUL N
Re-roofs
Signatemaf Appl nuncto'
ate
A ,AZOUS MATERIALS DISCLOSURE Type of Roof
will the applicant or futum building occupant an or handle henAous material
as defined by the Cupertino Municipal Code.Chapter 9.12.and the Health and Safely
Code,Section 25532007 .�t� All roofs shall be inspected prior to any roofing material being installed.
-.ria t]Yu
Will the applicant or(low m building occupant use equipment or dcvicu which If a roof is installed without first obtaining an inspection,I agree to remove
n hazardous air commitments as defined by the Bay Area Air Quality Management .all new materials for inspection.
Dise itO
❑Ycs
I have read the havardous aerials requirements under Chapter 6.95ofNcCalifor-
nuHcalth&Safety ,Seed s25505,25533 and 25534.1 understandthm if the Wilding
docs not eo.ar,y a a ten Nat it is epomihility territory she eceupanl of Ne
rcyvimmcnu which�slstls upriommm�cc ofa CcrlifipfOic
upulcyy Signature of Applicant Date
Owner or xntionerl seat D� (/�Da�� All roof coverings to be Class"B" or better