04050001 (2) CITY OF CUPERTINO77'- Fra�
BUILDING DIVISION PERMIT �1V;lFRlll
BUILDING ADDRESS: DOUG HERDA """"04-050001
ERMITN004050001
R'S NAME: PERMIT ISSUE DATE
ONE: SANITARY NO. CONTROL NO.
ARCHITEC AENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
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LICENSED CONTRACTOR'S DECLARATION JbDescri Description
Ui 1 batch,affirm Nmo
m 1 am licensed under provision of Chapter 9(co
mencing P
n< with Sation]OIq)of Divialon 3.f me euainess eM Profnsi...Code,and my lice..is
<� in full to.and affect
q'�z Lice..Class sec.11 REVISION--HALF BATHRM
z ppp Dam Contractor NO NEW PERMIT ISSUED/ORIG. 404030166
ARCHITECT'S DECLARATION -
1 undcnund my plas'hall W used as public records
C
3 Licen.d Prorcaional /!
OWNER-BUILDER DECLARATION
ef 1 hereby affirm than 1 L exempt s an Ibe Cocain Co License Law for me _
ii:p� following masa.(Saito 703 su Business and w.demolish,
Code:Any city or county
which its a bounce,also re consumer,alcor.improve,demolish,care pair ed gnemre
poor.its ...dpwwwotoithe the inion of forthe sucContractor's
(Limon Law
gamma.
8 (comm iscing wit Puntion700)the provision of NC Conusines'snd Professions
(C Craig
Sq.Ft.Floor Area al D CO
MAs 'ammesc Tempt Section 7000) bam;afr nftheeged Business and Cela)or Y
� Net he is exempt thcmfram and the bels for dm alleged exemption.Any violation of
Section 703 1.5 by any applicant for a permit subjects the applicant.a civil penalty of APN Number Occupancy Type
N
not me. an IN.hundred dollars(MLP Y YP
❑1,a owner of the property,or my employees with wages as Weir um compensation. 32613128 : 00
will do the work,end the gracttue is not intended mmilsmd footle(Sec.7044,Business
and Professions Cade:The Contncmrb License Law does not apply W an owner of Required Inspections
property who bull ds or improves memon,and who does such work himsel f or through his
awn employees,provided that such impmvemenu are notimmnded oroRered formle.If, _
however,the building or Improvement is sold within one year.(compmtion,the rimer.
builder will have the burden of proving that he did not build or improve for purpose of
sale.).
❑I,as owner of the property,am exclusively contracting wit licensed contnctum t0
contowl the prejeo(Sec.7044.Business and Professions Cade:)The Contracter'a U.
cane law does not apply to an owner of property who builds or improves them n,And,
ho contracts for such projects with a contumr(s)Raamd pursuant s the Contractor's
e®'1 tempt mule Scc B&P C for this nava.
er Dau�.3les�
RK ' C P NSATIOND ATION
I hereby a un penalty of perjury one of the following declarestn:
1 have and will maintain A CO ditcate of Canunt m self-insure for WmisesCampnn-
sation,u provided far by Section]700 of me labor Code,for the performance of the
work for which this permit is iaua&
❑1 hero and will maintain Worker's Compensation Insurance,g;required by Section
3700 of We Labor Coal for We performance of the work for which this permit is issued.
My Workees Compensation instance carrier and Polity number aw:
Cartier, Policy No.: _
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(Bar,seed..need not bacomamad if the Permit s faros hundred dollars($101)
.r leas.)
1 Unify then i c perf furnace of WE work for which this permit u immed,l shall not
em la an rsa enc u bee ub'ect to the Workers'C.m ensason
P Y YP l P
Laws of F'a1H^I• ^e
Np I TOA CA :If.after this Ccnifcate of Exemption,you should
become subject to the Workers C.mpmemion provisions or me labor Code,you mug
.JO forthwith comply with such provision or mix permit shall be deemed invoked.
.Zi M CONSTRUCTION LENDING AGENCY -
E
I bemhy Aron mo them is a construction lending agency for the Performance of
C' din work fur which this permit is issued(Sec.7097,Cih,C.)
1+7 A Lenders Name
]z Landers Address
U Q I certify that I have mad this application and sum that the above information Ls
l4.Hcaned I agree to comply wire all city and county ominances and sun laws relating to
DU building ensuuaion,and hereby authnrim muctenutiws of this city to enter upon me
t11 'baro-mentioned property for impacts..purpose.
(we)agree m save,indemnify and keep harmless the City of Cupertino against
s(aA
liabilities,judgments.costs and expenses which may in any way acme against mid City
of are
U z APPLICANTeUNDERrenh NDS Ang Of Ia Permit.
ND WILL COMPLY WITH ALL NON-POINT Issued by; Date illiil"l
REGULATI
,3 Re-roofs
Sit of annotator Data
AZARDOUS MATERIALS DISCLOS Type of Roof
Will the app icam or
future building Occupant atom arhandla hmardaus material
defined by the Cupertino Municipal Code.Chapter 9.12,and the Health and Safety
A.Scmea 25s5z(a)7 All roofs shall be inspected prior to an roofing material bei.
❑Yrs p 4C P P Y g g installed.
Will the applicant or future building occupant use equipment or devices which If a roof is installed without first obtaining an inspection,I agree to remove
fall havamous air contaminants u twined by me Bay Arca Air Quality Management all new materials for inspection.
District?
❑Yea Nu
I have mad the bmaclous materials mquirommmu under Chapter 6.95 of the Califon
nia Health&Safety Code,Saction 25505,25577 and 25574.1 understand that if me building
dors not cunendy have a unam,that it ts my responsibility m notify the aeupant or the
which must nor to iauanoe ora ccrtifnm or Ogga^p.acy. Signature of Applicant Date
er or anima ed p Dan, All roof coverings to be Class"B"or better