05020015 (2) CITY OF CUPERTINO I<+ vd1 < �a'Ya4e-^aj` "pc3
BUILDING DIVISION PERMIT CON'�RACTOR,INFRMATION ,
BUILDINO ADDRESS: YARON & NANETTE VIDAN-PELE PEaMITNo05020015
OWNER'S NAME: PERM USUBDATE
YAR
E: SANITARY OL NO.
A0.CHrrECf/ GINEER: BUILDING PERMIT INFO
BLDG O PLUMB MECH
O
Z' LICENSED CONTRACTOR'S DECLARATION
I Wrathy eRl m IM11 am licemed under provisions of Chapter 9(commencing Job Description
IN Section 71)(IU)orDivWon 3 o(de Business and Profession Code,and mylicame is
�i iLiemseanande° u g REVISION--IN HOUSE USE ONLY
FFFF Data contractor NO NEW PERMIT ISSUED/ORIG. 404040127
ell
ARCHITECTS DECLARATION
�i ry1 1 understand my plan.hall be uud As public mantis .
tad Licensed Pnttcssional
^ OWNER-BUILDER DECLARATION
.d 0 q 1 hereby.(Seco o n I em mempt wet Ute Casom,Coo License Law for the
i o o following moan.(Section 7 construct,
t,slurs and w,demolish.
Cade:Any oily or county
$ which its issuance,
• also to MnwcL alar,Improve,h Vomit on
rie pair any awauro
F S^
poor toiu enseditmomquims lM applicant for techp %*(, cense La (atsmm,m
erQ Net he iaicensed purtuantla ft provisions o(WCanuact"'s Lleenmisw(Chaper9 Sq.Ft. Floor Area Valuati 1115
$ (commencing with Section 7")of Division 3 M the Businessand profession,Cade)or +7
that he 4 eaempt thmftm and the buts fm the alleged ewnp ldn.Any violation of
Seecti me than byfive mApplicant for a Permit
l it subjow the Applicant,to a chat Penally of APN Number Occupancy Type
not❑I,as owner of the pmpmsy,or my employ^u with"Sea as their sale tmpenstion, 36908022 , 00
will do the work.and meAncient tanat intended oroffamel far Sall Business Required Inspections -
And Profession Code:The Contractors License Law dm not apply to an camer of q P
property who builds or improv thereon,and who does such wmk himself or thmugh his
own employ",provided deal such improvements ate notinteeded maffamud for sale.U.
however,the Wilding or Improvement is said within aro Sen of completion.the—I-
builder will have the Widen of proving that M did not Wild"improve fm purime of
sale.).
Ex 1.as owner of the property.am exclusively contracting with Iica sed conuacus Io
convect the pmjm(Sec.70".Business and Pmhnions Code:)The Contractor's Li-
cense Law dm not apply m an owner of property who Wilds or improves demon.and
who contracts fm such prejeeu with acontractnr(O licensed person,to the Contractors S
License Law. GL'�
❑l am exempt ander Se ,B h P/I..0 for this melon
1037(�l
r Dam 7 -0 l
RKER'S COMPENSATION DECLARATION
1 hereby&(Ilam under porosity of pcijuy am of W following dedarsdatts:
have and will maintain aCerdOmm of Consent m til(-inum for WarkeraCmpcn-
n.n provided for by Session 37M of use IaWr Code,(or the performance of the
for which this permit is issued.
have and will maintain Worker's Compensation Inumnce,u mquimd by Section
of the labor Code,fm the performance of the work for which this Permit is Wood.
Workers Compensation Inwnm earti"and Poliry number ate:
ier. Policy Na.;
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
IThta enin mad not Ise completed Ifft pewit It forms,hundred Mlles fillin)
or less.)
1 unify that in the perfonnanw of tho work far which this perms issued,I I
croI n non loan an ne Mcome cork'cltome ren' n on
Laws f California.DarrR �-oN `r
Applicant—
NOTICE
PPlicantNOTICE TO APPLICANT:If.after making this carinae of Ex>�you should
become subject to Nc Workers Compensation provisions of de,Labor Cache.you mon
0z fmthwidt comply with each provision"this p"mllehalf W deemed amied.
„zt M CON UCITONLENDING AGENCY
[-. hour y m that ser .a c. an con ^PI my for cp formence of
Dvi W wu fur ich ti's ad h sued( . 097, it.CJ
Who and .N
Z Ian rt.Addrev
V 0 1 cenlfy that I bare cad Ws applieuion and mm con do show in(am tion u
L[.. correct.1 agree m comply with all city and county onlinams aha stale laws nladng An
0 ars-!: building convection,and hereby anthonm representatives of this city to enter upon the
Ln shove-mentioned property for Inspection purpmes.
(Wc)agme as an.indemnify and trap harmles the City of Cupertino against
Iaq lobilithajudgmen0.cosu andexpelues which may In anyway aceta against said City
()7 in ealtsequenm of the irate ng of This peroo
F7 APPLICANT UNDER 111{{{0oS L COMPLY WITH ALL NON-POINT Issued by: Date
SOURCE REGUL n [/
/ Re-roofs
Egoat.m of A,. anuCanuacmr Dam
HAZARDOUS MATERIALS DISCLOSURE Type of Roof
Will W applicant or from Wilding occupant nam or handle hundm"About
as de0nd by tie Cupetline Municipal Code.Chapter 9.12.and tie Health and Safety
Cale.Section 25532(a)7 All roofs shall be inspected prior to any roofing material being installed.
0y. No
Will the applicant or future building by the B iso .Aiequipment m devices which
If a roof is installed without first obtaining an inspection,I agree to remove
hevaadnu,air canuminants u defined by the Bay Area Air Quality Management all new materials for inspection.
uicR
❑Yet No
(have mad the huaNtesma cels mquimncnu unJcr Chapter 6.93 of the Glifoa
niaHmlthgt Sefcly CaM, dons 03,25577 anU 233N.1 undm.und thmif th,Wilding
dm vete ppppppllyh an t It h my responsibility to nodl'y de M,PNI((the
requirem thio m no,toisuance:or?"fiumo�eupancy. Signature of Applicant Date
rraullonvedagcnl 4 OOflfl 0 Dam All roof coverings to be Class"B"or better