04080072 (4) CITY OF CUPERTINO
BUILDING DIVISION PERMIT CC1N I2ACTOR INFORMATION 4:
, -
BUILDING ADDRESS: PERMIT NO.04080072
8795 TTTqnN A.1.12
ER's NAME. PERMIT ISSUE DAIS
f)�
J SANITARY 0 ill,NO,
ONE:
ARCHITECI7ENGINEER: _ BUILDING PERMITINFO
BLDG ELECT PLUMB MECH
C7 O 0 O
Lap LICENSED CONTRACTOR'S DECLARATION Job Description
C I hereby affirm Nal I am licensed under previsions ocp
of Chapter 9(commencing
a with S 7")of Divi' 3 of the Bui n and P fessionyCride,nod my licenseis
S�?'5 Liewoutgsx,ndercea R NEW FRONT DOOR & SHED ROOF TO COVER W/6X6 SLAB
Lic s Lica
Dam Conti mr CONTRACTOR: SPIEKERMAN CONSTRUCTION
CHiT (CrS DEVA
K 1 under y plans shall M used as seer
�nWU
4: Licensed Pnafcssionel
`�< OWNER-BUILDER DECLARATION
noI herohy.(0rm that 1 1. eBusin from the Cmions o License Law for the
p o which(allowingex reason. (anon 703 1.5,Business and liofcasiom Code:Any city or county
which nyuima a permit to eonswm,alar,improve,h Permits,or repair any structure
w�'^ prion..its censed e.pursuant
ns,to tee the
ovisio antsof for sucContractor's
ontra tor's icausle asigned watammem
aNmhetilicensedpursuanttoNcofDiaimuofthe Colexure'sLicenseLaw(Chapter ode)9 Sq.Ft. Floor Area - Valua[�e7�079
u tst� (cdhe is morepthhatefoornand of Division3 of the
.,cdmaandon.Any
y 3� Nal he is exempt therefrom and to baso for Ne alleged exemption.Any violation of
Section 7031.5 by mry applicant for a permit subjects to aplificanl to a civil penalty of APN Number Occupancy Type
nor mom Nan five hundred doll...(SSW). ,
❑Lu owner ofthe propony,m imy s not
with wageuNei(sale compensation,,Businss
37518001 . 00
will do Prthework end the structure isnots License
Loffered awdo(orale(Sec.T1144,emoroe
and property
whiona Code:The acethemors and
Law uch nos apply Io an owner of Req IC S
property who builtle or improves thereon,and who does such work himself or through his
own employees,provided that such improvements are not intended or offered for rale.It.
however,the building ar improvement is said within one year of completion.Ne owner. AUG .7`' �oo�
builder will haw the burden of proving that he did not Mild or improve for puryu /'S
oof IJG ir7-
sale.).
❑I,az owner aj the property,,Business exclusively confessions with licensed cunmctou . BUILDING U I L D
come La the annot ppl(Sey.too n wneofand property
wh ions Cade:)The Conuebnrs add
w ,
wholaw does not apply loan owns of property wee builds or ant 16 to No tsw and N(V—
who conlracu for such projects with a eonlnctor(s)licensed pursuant N Nd Conuaetoh
` L nu Law. -
IamezemptunderSee. ,B&PCfor this Haran
er Data
WORKER'S COMPENSATION DECLARATION
I hereby aRren under penalty of perjury oro of the following declinations:
I haw and will maintain a Certificate of Consent to self-insane for WorkeesCompcn-
sation,u provided for by Section 37M of the Labor Code,for Ne performance or the
work for which this permit is issued.
E3I haw and will maintain Worker's Compensation Insurance,az required by Sdbuon
P00 of the LaborCode,far Ne performance of Ne work far which this permit is Issued.
My WOrkerS Campeaauan Insurance carrier and Policy number are:
Carrier. Policy No.:
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE -
(Thlsseetism need nor Lccomple rad iftin Permit is foronc hundred dollna(SIM)
or less.)
1 certify that in Op Romance of Ne work for which this permit is issued,1 shall not
employanypeN ..Data
manner azmnecome aubjceWore 5Co5 'u on
Lawson Cal Ice.Dau
Ap lican -W ICE�U AYVLI A :Iff a cr mako his ordimme of Exemption,you should
bcc abject to the Workeh Cam. tion previsions Of the Labor Code,you must
.,O forthwith Comply with such previsions or this permit shall be deemed maker.
z` affirm CONSTRUCTION LENDING AGENECY
I hereby airm that there is a construction lending agency far the performance of
> the work fur which this permit is issued(Sec.3097,Civ.C.)
Q Lenders Nameresi
z Lenders Adds
I,U
Q 1 certify Nu I have read this application and sum Nm the above information minting is
0 F bandit.l ague m comply with all city and countymUldwS Of and sou laws,r upon L e
�U abovengconsuucliomand hereby auNoprepusenurivca of Nis city mcnurupnn tM -
W .hove-(We)a md gree to aw.ity for inspection unifsad
keep ha
G (We)agree m sew,indemnify and keep humthss the City of Cupertino against
V1 liabilities,judgments,costs and expense which may in any way account against said City
U Z in consequence of the granting Of this permit.
APPLICA UNDERSTAN S AND WILL COMPLY W ALL NON-POINT Issued Issued by: Dale
SOURC GULATIO -1020.
Re-roofs J
rc of ApplicanUCofia ser e
HAZARDOUS MATE$ALS DISCLOSURE Type of Roof
IV Will Ne applieam or future buihling�mcupam atom or handle hawdous material
az dcOncd by the
Capetian Municipal Code,Chapter 9.12.and Ne Health antl Safety
e,selves f7fNo zsslz(a)7
❑YeAll roofs shall be inspected prior to any roofing material being installed.
z
Will the applieam or��ruulues building occupant asc cquipmdm or dmeds which -If a roof is installed without first obtaining an inspection,I agree to remove
emit harafdnus air contaminants az cormcd by the Bay Area Air Quality Management all new materials for inspection.
District?
❑Yes I NO
1 have read the hnandous maurialanequinments under Chapter 6.95 of the Califon
ilia Huith&SafdtyCW.,Secuoo 25505,2553]and 25534.1 undenland that it On building
Jutsa Icurrently haze un a I' rcaponsihi' m noury the occupant or the
nqu' entswMdn at missaaneevta0camorOccupancy. Signature of Applicant Date
weer ser aulhorizede eat vm
All roof coverings to be Class "B"or better