04050085 (2) CITY OF CUPERTINO
BUILDING DIVISION PERMIT deC,OTkAC' ORIN '(HrMATION:,=`
BUILDING ADDRESS: OM BUILDERS, INC PERMITNOO 4050085
\ OWNER'S NAME: PERMIT ISSUE DATE
g; SANITARY 0. CONTROL NO.
ARCHITEC(ENGINEER: BUILDING PERMIT INFO
BO O PLUMB MECH
Sop LICENSED CONTRACTOR'S DECIARATION JobD rC
1 hereby ai of Net 1 am of
Bal under provisions of,Code. 9(commencing
]���
with Sectionhereby 70M)of Division ar oli Needndeandvisions of hapten nd 9(myRwnci Is
a'q Ltf,..a.deffect, �I SFDWL-2 STORY (2167 ' L I
Dam Contractor ARCHITECTS DECLARATION GARAGE 504 S Q.FT. J s�
l undera and my Isms shall be used u public records '• 200rj
U Is VV
Licensed Profusional
OWNER-BUILDERDECLARATION BUILDING
i
�x 1 hereby allirm Nn 1 who
"tempt frommthe COnuamots U..law for the
a following mason.(Section 707 L5,Business and Profession Code:Any city or county ® N
B which requires a permit to construct,alcor,Improve,demolish.or repair my structure
_Z„ prior in its Issue=.also requires the applicant for Such permit m file a signed statement
�< drat he u licensed Inurement m the provision ec
of done Contrmes lnres Law 9 Sq. Ft.Floor Area Valuation
g $ (commencing with Section 7000)of Division 3.fthe Buaineumd Profwthm.Cade)m
5 5 that he Is"tempt therefrom and the basis for de alleged corruption,Any violation of 8350000
Section 7031.5 by any applicant for.permit subjects the applicant to a civil penalty of APN Number Occupancy Type
rot mese than five hundred action(M).
❑I,as owner of the property,army employes with wages u their sole compensation,
will do the work and the strutnun is not Intended w0@rcd fouak(Sm.7044,Bud•...
and Pmfecdon Cade:The Conaono,'s License law des not apply ne an owmer of Required Inspections
propenywho bulldsorimproves thercon,and whodOes such workhimolferthrough his
own employee,provided that such imprevxmenu ase not boosted aro@red fms.le.If.
however,the building or Improvement is said within an year of mmpledon,the Owner.
builder will haw de burden of proving that M did not build Or Improve fa purpose of
sale.).
O 1,as Owner of the property.am"elusively contracting with licensed umnuacton to
construct the project(Sec.7044,Business and Profesdnn Code:)Th Coax aeler's U.
even Law data not apply in an Owner of property who builds or Improves Nonan,and
who concocts for such projects with a cantracmr(s)licensed pursuant to the Connor's
License law.
p lamnem tun C. BB P C far this
i mason
Owner I k ►— Dam,,�LS(IT-
ORKER'SCOM SATIONDECLARATION
I hereby affirm under penalty of perjury ane of the fallowing declarations:
1"mad will mdnuin.Ce fl wof COuentmelf-inumforWartesCmnpcn-
town,es provided for by Section 7700 of the Inbar Code.for Um performance of the
work for which this permit is Issued.
❑1 haw and will maintain Wormes Compenadan Insurance,u required by Section
77W of to labor Code,for the performance of de work for which this permit is issued.
My Worker's Compeni mmst Insurance under and Policy number em:
Canter: Miley No.:
CERTIFICATE OF EXEMP110N FROM WORKERS'
COMPENSATION INSURANCE
(This section meed not Memnpleted Ifthe permit Is foreachundmd dollen(Slip)
or Ions.)
I certify that In the performance of the work for which this permit is issued.I shall not
employ any person in my mannyps.s'p pIAlEpfnembject to the Werkerd COmpcnadon
Laws of CalifrMia.Dam
Applicant
NOTICE TO APPLICANT.IL after making this CenlEcatc of Exemption,you should
become subject th the Worker's Compensation providau of the Labor Code,you mus -
.,z forthwith comply with such provtsiors or this Permit shall be demand revoked.
za CONSTRUCTION LENDING AGENCY
[..r I hereby afrnm that men iso construction vading.gency far the peffarmm of
Ci> the work for which this permit is issued(Sec.7097,Civ.C.)
GQ Lenders Name
0.z Lsnder's Addmsa
C)Q 1 certify that 1 have read thin applicatinn and sum the Ns,.bo.informNOn I.
correct.1 agree to comply with all city and county ordinances and sum laws mining to -
C) building construction.and hereby.uthoriar representative,of this city to error upon the
{27 shove-mcntimed property for inspection Purposes.
pyt (We)agree in save,indemnify and keep harmless the City of Cupertino agent
fq liabilities,judgments,corm and expenses which may In my way seem against said City
C.t z in consequence of the growing Of this permlt.
APPLICANT UND RSTANDS AND WILL COMPLY WITH ALL NON-POINT Issued by: Date
SOURCE REGI 0
A Re-roofs
Signatures(Appliwm/Comremor Dam
HAZARDOUS MATERIALS DISCLOSURE Type of Roof
Will the applicant or future Wilding occupant stare or handle harardom material
not dcOnca by the Cupertino Municipal Code.Chapter 9.12.and the Health and Safety
Code.Section 25572(01
[]yen WeAll roofs shall he inspected prior to any roofing material being installed.
Will the applicant or future building elcaPant use equipment or devices which If a roof is installed without first obtaining an inspection,I agree to remove
n huxdnus air conuminanu u defined by to Bay Area Air Quality Management all new materials for Inspection.
District?
❑Yes T)Nu
I haw read do hvaNws materlalsrequirements under Chapter 6.95 of the Califor.
meta Health&Sa(clyCodc,Section 25NI3,35577 and 25574.1 understood thulfthc Wilding
taw not currently haw.mnan4 Net It u my reaporWhilhy a nmily the oceupant of the
require n w wt m oasuanceof.Card lkaoofOcw Signature ofApplicant Dale
St "'Ir All roof coverings to be Class"B"or better
Owner Or amhodsd.ri —Dam
e-