00050216 (2) CITY OF CUPERTINO
BUILDING DIVISION PERMIT CONTRACTOR INFORMATION:
BUILDING ADDRESS: PERMIT NO.
1099 TUSCANY Pl_ PETERSEN—DEAN INC
OWNER'S NAME: APPLICAHON s"W050216
�'PDONIi: SANITARY NO. 05/S)fTJt6b0
VIOL ARCHI'I EC"LIENGINEER BUILDING PERMIT INFO
_ BLDG ELECT PLUMB MECH
�a
?FON
LICENSED but IDCONnsed under o,DECLARATION .IOb DCSCPIpIIOn
OZ_O 1hcrchy affirm mal1.3bcenxcd oilerproviaidlerfr,C, r9n";li wing
rnFu with Section NNXII nI Uivieinn3af the lfu&ineu anA l'mle.-inns Gxle.nnA myliccnrc
mf i.in full fma andttaj;
d K 6 6 Liccn.&e (�� Lic.p
Dae Cnnlractor Am
ac 3 a ANCHIT -S DECLARA ON
C Ef 0� I underoz d ny plain-hull be uwd a,,uhlie roll 1
a�S
� Y
7.
cecif pLioi Professional
aowrvER-BUILDERDECLARAIION T/0 SHAKES, RESHEET, ADD 40 YR. GRAND SE
1 hereby affirm mal 1 am exempt It i the Conmaaa's Licur,Law fnr the
[-Z following reason.(Section 7071.5.Business and Profession Cale:A,city or roomy
f S a
oluch requar,li tenant locousomict.arter.hapoo,dentolikin, I y surclure
yef pr t issuance. 1 requires t,l 11 uhpn alt flsignedNaenent
c.a ormato licensed pt to the powisims,oftheContractor Liol La (Chapter9 Sq. Ft. Floor Area Valuation
(ronwu"gw"h S,lion 7111X)11 1),,i,i tS f1 N I Profic,ion,Coot)
or that he is escntpr Ihercfmm and the basis for for alleged eumption.Any violation
of Section 7031.5 by any applicant for a 1 enalt subjects the applicant to a civil penalty
of am rm,re than live bun fool dollar.(&500), APN Number Occupancy Type
01,a,owner of Bw property,lir my cmplayee,with wage-a their sole ermpemaiun, tl
will do the work.and the slrucmm Is nor In¢nded or nlfmml for solo(Sm.70,44, Required Inspections
Ito-mess and Professions Code:The Contractor's Liame Law ares not apply a an q P
owner of pmperty Who buil&or intpnwcs thereon,and who docs such work himself
,it Ihmugh hie awn engtluyru.......iled that .Or irnpmvancnw oe am intended or
oReml for sale.If,hatever,the building lir impnrvanem is sold within one year of
mnpleflon,the ov mr-huilder will have the burden of proving that he did not build or
Improve for purpom ofsulcJ.
305 — FRAME
[11.a,owner(if he prolway,am exclusively contracting with licensed contracua,to
construct the project(Sec.7(94.Br- mrd Frofrss ,fits CoJi be Cm,o-act"^ 307 — INSULATION
License Law arcs not appy m an aw cr of .,ay who(wild m impnwes rherean.
and who ea..art, lot rah frniert.with a tontmaoas)licensed frustum tome 601 — ROOF TEAR OFF
ConVaclors License Law.
O l.,it carrot under Sec. .R&1'C for this reason 602 — ROOF PLYWOOD NAIL
Owner Date 603 — ROOF BATTENS
WORKER'S COM[FENSA EON DECLARATION 604 — ROOF IN—PROGRESS
I not.Ilio..under penaltynlperjury oar of the fnllnwht,declmtnioa,
❑ 1 hove rid will munrain a Certificate of Consent m self mute for Worker's
Comrmanc nn as work
for Iia by Sermon dissu of the LoMu Cralc, @a the
performance of the work fnr which this permit is issued.
I have and will maintain Worker',Compe...non In.wrunec an n'quired by Section
mac of the Laker Workers Cool for the ICTlbrmuncc of the and
pA foricy which this permit is /
Issuol.M,y,/Labor�C/uJde.forxthi—nnflo'rmmucoria�md Policy numberare:
Currier:�'�[�ree rolicy No.��z9P524 3/
C1 'I ICICATION OIs EXEMPTION FROM WORKERS' Q
COMPENSATION INSURANCE /r��
(Drs&comm aced nal be comploed il'thc permit Ix fm aw hundred Jollun V
(sla)or le"") -
1 ccnily the In the perbanunoe of the wuA fnr which his permit'm issued,1
shall not employ any person in any manner so as lir become subject to the Worker'
Cnmpen&ation Law-of California.Date
Applicant
NOTICE TO APPLICANT:If,afier making this Ccaili ale of INcradion,you should
become subject to the Workers Copba
Compensation provisions of the Lur Code,you must
Q O mLub.hh coo i,ly with such prm�ixinn,lir mi,11-1 if-ball he deemed revoked.
FtiCONSTRUCTION LENDING AGENCY
> I hereby anion that them is it conauucliou lending agency rat me Icrfnnnunm
flat,work far which lis pe.air is issued(Sec.3097.Civ.C.)
C1. Q Lender's Nave
Lender's Ardor,
V I ready that I have read this application cold ruse that the akwve information is
Las (r correct.I agree to comply with 4 city rand county oNionnecs and sure law.,misuing
V to building construction.and hereby uumorim reparwaratives ofthk city to enter upon
'y �] the uhave-mentional property for inspection purposes.
F„r y (We)a,rov in va.indeamnit'y and We,harmless the CayalC.,,,lnuaguino
N liabilities,judgments,mob and expemes which may in any ray acerae again&(said
Clly in.ud,,encc of Ihu gruntingof thio permit. p /�
APPLICANT IiRSTANDS NU WILL COMPLY WITH ALL NO'u),.�,OIT Issued b �"t-- Date `l
SOURCE .UL,TIONS. s/rf( „ y'
Signature of Applidi.nVontracmr Date Re-roofs
I IA7.ARDOUS MATERIALS DISCLOSURE
Will the appllram or future loolding oc:upam Num lir handle huardom material 'type of Roof
as refined by the Cupertino Mt.hic/ipal Cale.Chapter 9.12,and the Hcmt11 and Safety
Crile,Section 25532F07 4
❑Yrs Nn All roofs shall be inspected prior to any roofing material being installed.
Will the applicant orfarm building occupant use equiprcntordevices which If a roof is installed without first obtaining an inspection, I agree to remove
h
Drirumnluns fur cnnmrnintn nuns delired by the flay Amu Nr Quit try Management
Di1,oall new materials for inspection. Applicant understands and will comply with
l �/ye- Na ' all non-point source regulations.
1 have read the hwurdou&inatcrial,requirements under Cooper 6.95 of the
Califor
nia Hralth&tiafety Code.Sections 25505,25533 and 255N.1 understand that < �/ �O
if lbs hot Linn,does not"woolly Into,a naat the h is no,res,nnobil try Ra
s nti fy th ✓
e K s
occupant ofggftqqqthe requirement,which must be met prior m issuance of a Cenli
irate nl' ✓ l
(kcrpew
� ell Signature of A licant Date
Owner orauthmuc a Date All roof coverings to be Class"B" or better
OFFICE