08050070 CITY OF CUPERTINO
BUILDING DIVISION PERMIT .CON>TRACTQRai,NEU�I2.MA:T10111VVI
-
BUILDING ADDRESS: PERMIT NO.
22292 RFGNART RT) VIA B
-R'S NAME: PERMIT ISSUE DATE
i�
\'- ', KAT14* *ATES 4609'
Ip A CONTROL N0.
a
650) 948-1077
ARCHITECr/ENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
1= C=
u00 LICENSED CONTRACTOR'S DECLARATION Job Description
mC 1 hmcby affirm Nn
al 1 tea licensed under provision of Chaps 9(commencing P
�OGt with Section 700B)afDivision 3ofdw But.and Professions Code.and my licensees
in full forteand cffcct. REVISE,MOVE EXT IN 1ST&2ND FLRS, REMOVE INTERIOR
pvnz Licesconchum Liet
=Fp once Cmunster WALL IN BASEMENT, FAMILYRM & TRNSFR LOAD TO
ARCHITECTS DECLARATION
I undemand my plans"I W urA U Public mcarN BASEMENT WALL S-1, S-2&S-3 ORG#07090124 NO NEW
;e
LLa L"ernsd Pmfcss;anal
5 OWNER-BUILDER DECLARATION
1 Mmay 0Rrm that I am usempt from the CaobamMa License Law for the .
p O following meson.(Scenm 70313.Business and Professiva Cade:My city or county
which requires a permit to construct,ober,improve,demnlisk m repair any structure
Elm prfurmsficcr mlpuresumquime theapplicamfor Communes
Lmdsukmcnt
Elm kliccnxd puratmlmNc povisfont oftW Conuacars L�mnse LwlChapmr9 Sq.Ft.Floor Area Valuation
Yk$ 'atM is mempth Smerma% outm hasison3o(NCeged euand Ra Myvi Cade)or
Natio u exempt tberefmm and the Ease for be alleged Plicanm.My violation of
Semon 7031.5 five
any red dont for a pcmrit subjects the applicant N a civil pmairy of APN Number Occupancy Type
cot more Bun five hundred dollars(SSW}
❑Lasowm of the puciumcarmy wntended orNwagesuthe(Sm.c44.Bunems 36647015 . 00
will do thew..and the he Com a not intended or Offe..ed dos.1 apply
too14,...of
ries arafetkW Code:The Cn;flumom,License Law does not apply lf,t ownv is Required Inspections
OwnmywWWildaorire hatsuch imn,andwho doenouchwort himselfar through his
owneer,me
uilding r i that such improsemmuare nm;nuMNma@red for sale If.
bmvew,Ne Wilding or improvement u that
within mo Wild of completion,profor the case of
sale.). will have Ne burden of proving Nu W did cot Wild a improve far purpose of
ukJ.
❑1,a Owner of be property,am delusively contracting with limned contractors to ,
construct the Project(Sec 7016,Business and Professions Code:)The Coowmm's Li-
ve Law does not apply as an owner of property who Wilds or improves thereon,and,
who contracts for such projects with a contractor(s)licensed pursuant no the Conuacmfa
Licence Law.
I ore exempt undo See .B&PCfor Nis recon
Dam
WORKERS COMPENSATIONDECLARATION
V I hereby affirm under penalty of perjury one of the following declarations:
I have and will maintain a Certificate of Consent w self-insum for Wo lunsCompen-
dm,u pmvidW fm by Smtion 37W of the Ute r Code,for Ne p rfomanm of the
wort for which Nu permit is issued.
❑1 have and will mainwn Worker's Compensation Interstate,as required by Section
37W of the lahm Code,for dm Performance of the work for which this Permit is Issued
My Wraimes Campeuauan Insurance carrier and Poll,number are:
Cartier. Policy No.:
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(Thu seetim need cotbeeamplemJ ittK permit Is fevoue hundred dollars($100)
or kas)
1 terdfy But in the performance of the work for which this Permit is issued.I shall nm -
employ so,persaninany.,so b came tab'nth the Wmkers'Comperua0ota
I!of Calipmem.Desk�r —
Applicano rt ,
NOTICE TO APPLI NI:IL after mating Nu Certificate of Eaempdon,you should
baome aubjen m me Vartcfs Compensation provisions a the labor Calc,you must
.,O forthwith comply with such provisions or Nu permit shall W dmmrA reveled. ,
'Z CONSTRUCTION LENDING AGENCY
Ihereby afh mNu there tea connotation lending agency for du performanceof
!Yi >
the work for which Nis permit Is issued(Sec.3097,Or.C.)
Q Landers Nurse
=z Irnders Address'
U O 1 certify that 1 have read fids application and soon Nu the stove mr cr tt un Is
Iy H const l aged to comply with ill city ami county ordinances and state laws relating to
�U Wilding construction,and Wreby sermonize opmanmInfi a of this ciry u enter upon Ne
�fy a1mvemendomd property fm inspection purposes
p), (We)agmc he eve.iMcmnify tab keep harmless the City of Cupertino against
rF.r h liabilities.judgments.cosu ande.N.which may in any way amueUsual.card City
U z in consequence of the granting of this pmnit.
^
APPLICANT UNDERSTANDS AND LL OMPLY WITH ALL NON-POINT Issued by: Date �-
SOURCE R ULATI
/f E 0
RTL mcn 6 Re-roofs
Signuu of pplicaHAZAR cm� Data
HAZARDOUS MATERIALS DISCLOSURE - Type Of ROOF
WIII IMapplicam s future Wilding ompant sm c ter handle Incautious manorial
fined by the Cmier;m Municipal Code.Chapter 9.13.and the Health and Safely
.Satire 25532(a)7
❑Yes ONO All roofs shall be inspected prior to any roofing material being installed.
09;11 theapplicant ter foam building Occupant use I mens or devices which If a roof is installed without first obtaining an inspection,I agree to remove
t, g p warp all new materials for inspection.
1 havardna air eonumimnu u defined by Ne Bay Am Air Quality Muagcmem
�Iel7
❑Yes Apo
I have mad Ne haardeumaarialsmquiremcnu under Chapkrd.95 of Ne Glifor-
niaHulth&Safety Cade,$cedmu255U5,35533and25S34.lund nwdthmllthc Wilding
docs not Imre ly have a Gana that It is my,revponubility N notify the maupant of Ne
mqulmmcnes h;ahmat prm mu cmincunifmau`rypmry' U Signature of Applicant Date
// All roof coverings to be Class'W'or better
Owner o au amens,gem Dare