07010041 CITY OF CUPERTINO
BUILDING DIVISION
PERMIT1I`L'g:ATt�1R TNEtRATI�N•
BUILDING ADDRESS: PERMIT NO.
7414 TIPTOE LA BR
OWNER'S NAME: PERMTT ISSUE DATE
ROY LORD 385 S PASTORIA AVE 01/08/2007
ONE: SANITARY NO. CONTROL NO.
(408) 3C6-6553
ARCHITECT/ENGINEER:
BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
O O LICENSED CONTRACTOR'S DECLARATION Job Description
c u r- I hereby affirm that I am licensed under provisions of Chapter 9(commencing
=z m with Section 7000)of Division 3 of the Business and Professions Code,and my license is 2 BATHF.00M REMODEL, NO STRUCTURAL CHANGES
? y in full force and effect.
? License Class Lic.8
_m Date Contractor
I` ARCHITECTS DECLARATION
jm U I understand my plans shall be used as public records
DW
4 G y Licensed Professional
y OWNER-BUILDER DECLARATION
+<X 1 hereby affirm that 1 am exempt from the Contractor's License Law for the
E O O following reason.(Section 7031.5,Business and Professions Code:Any city or county
K ru which requires a permit to construct,alter,improve,demolish,or repair any structure
Z yam' prior to its issuance,also requires the applicant for such permit to file a signed statement S Ft.Floor Area Valuation
e that he is licensed pursuant to the provisions of the Contractor's License Law(Chapter 9 q $57524
YF (commencing with Section 7000)of Division 3 of the Business and Professions Code)or
y drat he is exempt therefrom and the basis for the alleged exemption.Any violation of
Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of ARN Number Occupancy Type
not more than live hundred dollars($500). 3 5 9 3 2 0 E 0 •W
❑1,as owner of the property,or my employees with wages as their sole compensation,
will do the work,and the structure is not intended or offered for sale(Sec.7044,Business Required Inspections
and Professions Code:The Contractor's License Law does not apply m an owner of q
property who builds or imprnves thereon,and who does such work himself or through his
own employees,provided that such improvements are not intended or offered for sale.if,
however,the building or improvement is sold within one year of completion,the owner-
builder will have the burden of proving that he did not build or improve for purpose of
sale.).
Qfll"as owner of the property,am exclusively contracting with licensed contractors to
construct the project(Sec.7044,Business and Professions Code:)The Contractor's Li-
cense Law does not apply to an owner of property who builds or improves thereon,and.
who contracts for such projects with a contractors)licensed pursuant to the contractor's
License Law.
❑1 am exempt under Sec. B&PC�forr this reason
Owner Dat 0-1 iLS2 SSL,/
WORKER'S CO PENSATION DECLARATION r
I hereby affirm under penalty of perjury one of the following declarations:
❑I have and will maintain a Certificate of Consent to self-insure for Worker's Compen-
sation,as provided for by Section 3700 of the Labor Code,for the performance of the
work for which this permit is issued.
❑I have and will maintain Worker's Compensation Insurance,as required by Section
3700 of the Labor Code,for the performance of the work for which this permit is issued.
My Worker's Compensation insurance carrier and Policy number arc:
Carrier. Policy No.:
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(This section need not be completed if the permit is for one hundred dollars($100)
or less.)
i cenify that in the performance of the work for which this permit is issued,I shall not
employ any person in any manner so as to became subject to the Worked Compensation
Laws ofCalifornia
Applicam
NOI7CE TO APPLiCA ,atter making wis Certificate of Exemption,you should
become subject to the Worker's Compensation provisions of the Labor Code,you must
Z forthwith comply with such provisions or this permit shall be deemed revoked.
z OCONSTRUCTION LENDING AGENCY
Er rte. 1 hereby affirm that there is a construction lending agency for the performance of
the work for which this permit is issued(Sec.3097,Civ.C.)
W Q L.endces Name
az Lender's Address
U C) I certify that I have read this application and stare that the above information is
[L►� correct I agree to comply with all city and county ordinances and state laws relating to
0 V building construction,and hereby authorize representatives of this city to enter upon the
above-mentioned property for inspection purposes.
�"r nWi (We)agree to save,indemnify and keep harmless the City of Cupertino against
tJ liabilities,judgments,costs and expenses which may in any way accrue against said City
V z in consequence of the granting of this permit
APPLICANT UNDERSTANDS AND WILL COMPLY WiTH ALL NON-POINT Issued b,': Date
SOURCE REGULATIONS.
ka?, Vs-p , Re-roofs
AionsimDitto
HAZARDOUS MATERIALS DISCLOSURE Type of Roof
Will the applicant or future building occupant store or handle hazardous material
as defined by the Cupertino Municipal Code,Chapter 9.12,and the Health and Safety
Code,Section 25532(a)7 All roofs shall be inspected prior to any roofing material being installed.
❑Yu
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
:mit hazardous air contaminants as dcftncd by the Bay Area Air Quality Management all new r laterials for inspection.
District?
❑Yes
1 have read the hazardous materials requirements under Chapter 6.95 of the Califor-
nia Hcalth&Safcty Cade,Sections 25505,25533 and 25534.I understand that if the building
does not currently have a tenant,that it is my responsibility to notify the occupant or the
requirements which must be met prior to issuance of a certificate of Occupancy. Signaturc of Applicant Date
Owkr-cw-authtXi7zdagent atc- All roof coverings to be Class"B"or better