04020163 (4) CITY OF CUPERTINO
BUILDING DIVISION PERMIT 0MT'AAG-TOR INFORMATION
BUILDING ADDRESS: ADF CONSTRUCTION PERMIT"°04020163
ER'S NAME: PERMIT ISSUE DATE
N
ONE: SANITARY NO. CONTROL NO.
4082819177
ARCHITECTlENGINEER: BUILDING PERMIT INFO
r__1 ELECT PLO O
+86 LICENSED CONTRACIOR'S DECLARATION
I bertby affirm that 1 am licensed under previsions of Chapter 9(Commencing Job Description p o
i wiNSttton 7IXM])of Dividon]°five Bu and Professions Code
.and my ikota is �'�®�p��
<� LI«;,l.le tle 8 ' BATHROOM UPGRADE f� Y[®
Date I ARC ffECl•gCentI�CL
t- A A IDI APR 0 6 2004
myphhaIw d =,
3 Lice onel Q
3D OWNER-BUILDER DECLARATION BUILDING
1 hereby affirm that I am exempt from die Contractor's License Lew for the
0O following meson.(Section Tin 1.5,Business and Professions Cale:Any city or county
$ which requires a Permit m cnnsmitt eller.improve.demolish,or repair my structure nnn
'^ priors its issuanec,also requires line applicant for such permit to rile a signed imminent
Net he is licensed pursuant o the provisions of the Canoncmr'sLans Law(Chapter 9 Sq.Ft. Floor Area Valuauon
(commencing with Section 70001 of DBusinession 3 of she Business and Professions Code)or
that be u esempl therefrom and the buss for the singed exemption.My violation of
Section 70713 by any applicant for a permit subjects she applicant to a civil penally of 3 9SN30fter0 0 Occupancy Type
not mom than Eve hundred della.($500).
Lo he cuk the dioperty,o,mYemployeu or
rNwegesutheir Cele tom,Business
will do thewonk,and e:no Cure a not intended a Law dontl fon,apply w an Business
and Crty wh ons Code:The Centimmum,License Law doss not apply if an owner is Required Inspections
propertyww .pronrlmpmvesNharpinatmmusdwho dasauchwork himselfor Nosab Ma
own employes,provided that vemimpmvemwt art not Intended a oartd the ow.r.
builder,Newildinguhnpmvementgloldwithinone]ear of completion,the°,seen
builder will have the burden of proving Nat be did not build or improve for purpose of
ole.).
❑I,as owner of the property,am uclusively convecting wish licensed Contractors to
construct the pmject(Sec.7044,Business and Pmlesslons Code:)The Cm=mr's Li.
cense law does not apply to an owner of property who builds or impmns,Ihemon,and
who contracts for such prejects with a convecmt(s)licensed pursuant in the Contractor's
Lice.law.
❑IamexempiunderSm .B&PCforthismason
Data
WORKER'S COMPENSATION DECLARATION
t 1 hereby same under penalty of perjury ane of she following decimations:
❑I have ponvid 1 for by Section
37M of the Labor
Code,sum(m performance
Ce of the
anon,r pre h thi for by Section 7700 of the labor Code,far the performance of Nc
work for which this permit Is issued.
❑1 hove and will maintain Worker's Compensation luuranCe,u required by Section
77W of the La Cade.for performance of Ne wort for which this permit is issued.
My We es penMlen eerier and Pull,number am:,^ `D
CERTIF ATEOCOME(FFNN))EX(.EEM99PTON A,{MM WORKERS' 3
(This section need he wMfipbN�dl Ni permltlaf r ne hundred dolmmn IW)
or less.)
1 certify Nm in the perfomuncc of Ne work for which this permit is issued.I shall not
employ any person in my manner an as in become subject to Ibe Workers Compewdon
Laws of California Date
Applicant
NOTICE TO APPLICANT:IL after mmking this Certificate of Exemption,you should
become subject in the Wohefs Compensation provisions of the Labor Code,you must
.J 0 v foMwith comply with such provisions or this permit shall be darned revoked.
fE"i CONSTRUCTION LENDING AGENCY
~ I hereby arm Net there is a committee lendinggency for Performance Perfoum:e of
athe work for which Nu permit Is issued(Sec.3097,Civ.C.)
W Q Lender's Name
.a7 Z Larder's Address
U 0 1 Certify that I have mad this appliuton attd sum that Ne above information is -
Ls U cornett I agree to comply with all city and county ortimmco and sum laws relating at
0 building convection.and hereby mthodre reprommaacs of this city to enter upon the
W above-mentioned property for Inspection purposes.
FL (We)agree to save,indemnify and keep humins,the City of Cupertino against
ti liabilities,judgments.costs and expenses which may in any my mcsue agaimi aid City
C)Z in consequence of the granting of this permit.
�'•' APPLICANT NDERSTANDS ND WILL COMPLY WITH ALL NON-POINT Issued by: Date
SOURCE R LAnO[4S.
(Fi^ iso Re-roofs
Sig t fApplicaHAZARc r Date
HAZARDOUS MATERIALS DISCLOSUR Type of Roof
Will the appilcam or future wilding occupeentstoredcladdic hmallom metenel
as derived by the Cupertino Municipal Code.Chapter 9.12.and the Health and Safety
,fir&,S.qLC.25532(a)? All roofs shall be inspected prior to any roofing material being installed.
s
miss the applicant or from wading a ap,m ase equipment or devices wroth If a roof is installed without first obtaining an inspection,I agree to remove
emit huaaidous air Colonel...us as defined by the Bay Area Air Quality Management all new materials for inspection.
District?
Yes "fl
l mflo
amri
1 ms mail Nw
e aalsmquimmenmunder Chapwr6.95aflhcCalifor-
ria Health&S2,,Cede,Seetiuu25505,25577 and 25574.1 t ndeaund tiutif dm wilding
does not currently ve a mmm,Nat it u my remonsihilhy m redly Ne uxupant of the
rtquiremmus.hi uuwmet rmiumaneeefmceniricate0'O7; Signature of Applicant Date
..2 D
Own' Fora .ad mgt., Dam All roof coverings to be Class "B"or better