04040052 (2) CITY OF CUPERTINO "'* M
BUILDING DIVISION PERMIT xCON=CRACTURffNFORMAZ�I®Ni -
,.. .'®2�.iRe r.._Yv?a3R,r.�^yrs'..° <•i-c rt ?S sem.
aDILDwcaoDREss: PERMIAN BUILDERS INC. PERMIT NO.
ER'S NAME: PERMU MUEDATE
MWALT.R/STEGNER A7770
05NE:I SANITARY OL NO,
ARCHITECTIENGINEER: BUILDING PERMIT INFO
BILDO ELECT PLUMB MEACH
O
JCp LICENSED CONTRACTOR'S DECLARATION - "" Job Descrl tion
1 thereby affirm that l am licensed under provisions of Chapter 9(commencing p
with section 7")nfDivieion 3 of In Deal.and Prowasi"m Code,and my heenx I.
ifull fo¢e and CUML
z LicenseCim Le.g REVISION--WALK DETAILS
in— Date G°"DEC
ARCHITECTSCart DECLARATION NO NEW PERMIT ISSUED/ORIG. ##03120023
I understand my lila..shall be used As public mi
3 U
i fid Lkcnxa Pm(ossianel
OWNER-BUILDER DECLARATION
I herchy.(Sent Na,1 1. exempt(sum Ne Cations rd License Law for the
F.
li O which re wvon.(Sudan](131.5, t,Business and vet de tans Code:Any city m ceunty
$jai pd.i requires a Pewit to construct alar,improve,dct ore pair any anuwrc
FZ< priuwiuivumee,ru ro 1.due thovisio csof for snehdpermitU-noaigawdautemen,
F o ,haheencingsedpum,anita0teprovisious3da ofthenuinessalleevcLaw(Code)to Sq.Ft. Floor Area Valuation
$83
s (commencing h exawith Condon .4 of basis for
of al Banner and Predication An innsGrdc)of
S hes he V exempt hcmfrom and dte baa far am alleged exemption.Any violation of
Section 7031.5 by my applicam for a permit ubjects the applicant to a civil penalty of .APN Number Occupancy Type
Act mom Nan firs hundred dollen(5500).
I,uownerofdwproperty,ormyemploytnWlNweg..uhe'vsokcompenxdon. 35907005 . 00
will do am work and the swctule imminwnded orone,ed forme(Sm.7044,Builme••
and Professions Code:The Conux,aYs Lia,ue Law daes not apply w an owner of Required Inspections
property who Wildsorimpara hereon.and who dossohworkhimselfor0uough his
awn employees.provided Na,such Improsemenu are not intended oroffered for sada If,
however,the building u improvement is sold wihin"fie year of mmpkdon.the owner
Wilda will have Ne burden of proving Na he did net build or Improve for purpose of
ale.).
1,As owner of the property,am exclusively contracting with licensed contractors,o aJ
sun the pmnot (Sec.o an Business and Professionswho
Wilds
Code:)The t;then me. n
L
Law d fiat ply to an ownu a(propeny who W lids or improv Newon,and
who con u ra projecu wilhaconaranortq licensed pursuant in Ne Conuscmfs
Lic ran v
❑Iw a der6eC .Bk PCfachl....
Date s
i KER'S COMPENSATION DECLARATION
hereby afRrm under penalty of perjury one of we follolgplala alon.:
I handed will maintain aCerifialeaf Coen,wself-imum fu Worker's Compere
cation,as provided for by Section 3100 of the Later Code.for ad Performance of he
wok for which this Permit is issued.
❑1 bays and will maintain Worker's Compensation Insurance.As required by Section
3100 of the Labor Code.for the Performance of the tank for which this permit Is issued.
My Wokefs Compensation Insurance artier and Policy number art:
Carrier: Policy No.: ,
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
reds section need nm be completed How Permit Is rorone hundred dollars(SIM)
or las)
I emify puts in the Performance of the work for which this Permit u laved.I shall not
employ any person in any mannerx 0 to Wenam MbjCCI to lite Workcrf Compensation
Laws of Califnmia.Dow
Applica,
NOTICE TO APPLICANT:If,after making this o d riCRa of Exemption,you should
become anbjeet to than Worker's Compensation provisions of the Labor Code,you mum
Z forthwith cereply with such provisions or this permit Nell be elected envokcd.
ZO CONSTRUCTION LENDING AGENCY
t—, I hereby affirm that them iso aruwmino loodoliaecnry,firtite perfurmanau(
a> we wok for which Oda permit is load IS..3091.Civ.C.)
Undoes Namc
D z Under'. ddress
V O 1 certify that 1 have mad this application and saw that the above inrom,atiun is
lt� !+ core..I agree to comply with all city and county ordinances and suite laws rtdaling to
p lr.'J building construction,and hereby medicare representatives of this city to enter upon be
>' aloin-mcndonW pmprty for inspection PugaxL
F t], (Wc)a to vet indcme and keep Mnnless he City of Cupertino Against
CA liabili0u,j.1Q n is Add cape....which may In my way accrue against said City
fJz in wmequerfc of ranting of his permit
APPLIC R D WILL COMPLY WITH ALL NON-POINT Issued by:940zo Date
RC AL5f
Re-roofs
of mu connector a Dow
HAZARDOUS MATERIALS DISCLOSURE Type of Roof
Will the applicant orfuture Wilding ucupan,sure uhandle harsrdous material
defined by be Cu crime Municipal Code,Chapter 9.13,and he Hcalh and Safety
.Se IZ.25532(a)? /a All roofs shall be inspected prior to any roofing material being installed.
Yu 1!
W01,tic applicant or fuwrc building occupant tax equipment or devices which If a roof is installed without first obtaining an inspection,I agree to remove
7d.
l,m ardnua air conwminanu defined by he Bay Area Air Quality Management all new materials for inspection.
uict?
❑Yes Nu
Iha adhehaoudnusmucriaismquimmenuunder Chapwr6.95ofthe Califon _
Fial cry Code.Su9om 25505.25577 anJ255J4.1 undcraad waif ate building
nti L tha it u my responsibility m notify me ocenp rt of ac
m be me,priorwisuanaohcmilc ofoccuparcy. Signature of Applicant Date
arammonvcaasen, Da,e All roof coverings to be Class"B"or better