07010082 CITY OF CUPERTINOow
BUILDING DIVISION PERMIT � `I2ATC? I (?RMATIf3N:
BUILDINGADDR S: PERMIT NO
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OW R'S NAME: _ r ,, PERMIT ISSUE DATE
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r - ^ M- ^ SANITARY NO. CONTROL NO.
ARCHITECT/ENGINEER: BUILDING PERMIT INFO
v /tY ,�� f ✓ �� / BLDG[� ED PLUMB
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=UO O LICENSED CONTRACTOR'S DECLARATION Job Description
r- I hereby affirm that I am licensed under provisions of Chapter 9(commencing p
-z rt. with Section 7000)of Div'' 3 of dw Business and pjof my license is
4 4 in full force and effect 5
D44
4§ D nsc Contgracwr
e -' ARCHITECTS DECLARATION
D
U 1 understand my plans shall be used as public records
o.
4 C H Lhcehhse11 Professional
rn OWNER-BUILDER DECLARATION
+< I hereby affirm that I am exempt from the Contractor's License Law for the
i in O following mason.(Section 7031.5,Business and Professions Code:Any city or county
t Iii which requires a permit to construct alter,improve,demolish,or repair any structure
Z3 Z prior to its issuance,also requires the applicant for such permit to file a signed statement
F xthat he is licensed pursuant to the provisions of the Contractor's License Law(Chapter 9 Sq.Ft.Floor Area Valuation
y $ (commencing with Section 7000)of Division 3 of the exempt therefrom and the basis for the allBusiness and Professions Code)or ^�
drat he iseged exemption.Any violation of
Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of APN Number Occupancy Type
not more than five hundred dollars(5500). r .-..
Q 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.704t,Bumness Required Inspections
and Professions Code:The Contractor's License Law does not apply to an owner of
property who builds or improves 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.).
❑I,as owner of the property,am exclusively contracting with licensed contractors to
construct the project(Sec.7044.Business and Professions Cade:)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 contractor(s)licensed pursuant to the Contractor's
License Law.
❑1 am exempt under Sec. B&P t for this reason
Owner Dam
WORKER'S COMPENSATION DECLARATION
1 hereby affirm under penalty of perjury one of the following declarations:
t]1 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.
15 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 Compe—]murance c sad Polity number arc: �{
Carrier `x'1'0. Ptality N.-
CERTIFICATE
o CERTIFICA E OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(This section need not be completed if the permit is for one hundred dollars($100)
or less.)
I certify 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 become subject to the Workers'Compensation
Laws of California.Date—
Applicant
NOTICE TO APPLICANT:If,after making this Certificate of Exemption,you should
become subject to the Worker's Compensation provisions of the Labor Code,you must
Oforthwith comply with such provisions or this permit shall be deemed revoked.
z r" CONSTRUCTION LENDING AGENCY
E r 4 1 hereby affirm that there is a construction lending agency for the performance of
> the work for which this permit is issued(Set-3097,Civ.C.)
W Q Lender's Name
Z Lender's Address
U O I certify that I have read this application and state that the above information is
t>.► correct.1 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
W above-mentioned property for inspection purposes.
Ha (We)agree to save,indemnify and keep harmless the City of Cupertino against
.,to liabilities,judgments,casts and expenses which may in any way accrue against said City
V z in consequence of the granting of this permit O
►�+ APPLICAN4%n
WILL COMPLY WITH ALL NON-POINT Issued by: Date
SOURCE R ,?
Re-roofs
Signature of ApplicanUContractor ale
HAZARDOUS MATERIALS DISCLOSURE Type of Rc of
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)?
0Yes 1XNo All roofs stall be inspected prior to any roofing material being 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
.aft hazardous air contaminants as defined by the Bay Area Air Quality Management all new materials for inspection.
District?
0Yes 6No
1 have mad the hazardous materials requirements under Chapter 6.95 of the Califor-
nia Health&Safety Code,Sections 25505,25533 and 25534.I understand that if the building
does not currently have a tena that it is my responsibility to notify the occupant of the
requirements whit t prior td fssu cc of a Certificate of Occ pan
Signature e f Applicant Date
*'
Owner trrauth agent 1 All roof coverings to be Class"13 or better
,* Z.3 gey
CITY OF CUPERTINO M010061
R�,ROOF
CUPERTINO PERMIT APPLICATION FORM
APN# -3 , 3(1, —C /a I
Date: I ! O
Building Address: 16c2 �2 AJ WCAIDI '
Owner's Name: 6149 AiDA n 1,IM4� Phon #:
Contractor: v j� �, . � License#: F-S
Contact: 4674 )S Cupertino Business License#:
Type of Roof Covering:
Existing: Proposed:
❑ Built-Up Roof ❑ Built-Up roof
❑ Asphalt Shingles Asphalt Shingles
Wood Shakes ❑ Wood Shakes
❑ Wood Shingles ❑ Wood Shingles
❑ Other(Specify) ❑ Other(Specify)
Number of existing coverings ❑ Provide I.C.B.O. Report#
XTo be Removed ❑ Provide Mfgr.Installation Specs.
I Have Read,Understand and Will Comply With Cu ertino's Tear Off Policy:
Jo�,DL ription: ;�� YO, Lem
Residential Commercial ❑
Fire Zone: Yes ❑ No ❑ Confirmed with Planning Dept. if
there are any restrictions: U
Cost of Project: 6, 00o-oo
Type of Constriction: Occupancy group:
Qty. if
Applicable Fee ID Fee Description Fee Group
BPERMFEE Bldg Permit Fees BUILDING
BENERGY Energy BUILDING
BSEISMICRE Seismic Fee Res BUILDING
BSEISMICOM Seismic Commercial BUILDING
BPLANCHK Plan Check Fee BUILDING
BUSLIC Business License BUILDING