08090045CITY OF CUPERTINO
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BUILDING DIVISION PERMIT
COFIR.ACTORNFQ,RMTTf1N_;
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BUILDING ADDRESS:
PERMIT NO. "
10280 BONNY DR
TBD - TO BE DETERMINED
08090045
R'S NAME:
PQLWT ISSUE DATE
TRAC VU
10/16/2008
PHONE:
SANITARY NO. CONTROL NO.
ARCHIIECT/ENGiNEER:
BUILDING PERMITINFO
BLDG ELECT PLUMB MECH
LICENSED CONfRACMICS DECLARATION
Job Description
1 hereby affirm tMt 1 am licensed under Provisions Of Chapter 9 (commencing
with Section 70(gofDivision 3 ofNe Business arld Professions Code, and my license u
REMODEL-ENLARGE(E)FAMILY RM INTO PARTIAL GARAGE
in full forte and drat
License Clata Lica
AREA 45', INCLUDES STRUCTURAL, NO RE -ROOF. "
Dam Cowman, "
ARCHI=rS DECLARATION
1 understand my piano shall he used as Public records
"
Liuved Professional
OWNER -BUILDER DECLARATION
,
I tareby from that I mer, exempt from the Contractors License Lou, for the
following reason. (Section 711313, Business and Professions Code: Any city or county
which re,ulw a permit t0 enmreCt. alYl, iolumme. dem-filh. m -Four Ny LNeture
prim w its issuance, also requires the applicant for such permit w filea signed statement
contractors Ueens Low (Chapter 9
Sq. Ft. Floor Area
Valuation
deal W is licensed pursvnt w the provisions oftW
(commencing with Section 70(10) of Divukm 3.1' the Business and Protections Code) m
$8000
than he u exempt Nertf can and the basis for the alleged exemption My violation of
Number
Occupancy Type
Section 70313 by airy apPlkant (m a permu Wbjecta the appluant m a civil penalty of
mor, mmm than fiw hundred dollars (35001
3 5 9110 3 8 : V
❑ Lu owner of Ne propmty,mmy wployw with wagnaslWbmle compewdon,
Required Inspections
will do Ne wort and Nesueown, I not Intended maRered for ask(see7061. Busimen,
and Prorestlom code The Canuxtors License law don Out apply w an owner of
property who brildamimpmwsdmaron,,nd wW doessuchworkhimrelf or through his
own employees. provided than such imprommcnu tae not intended muRen d for sale. IL
however. the Wilding m imprmvnent u mid within one year of oompledes. the Owner -
Wilder will bur a the Immune of Hewing Nat he did nut Wild Or improv for purpose of
tale/.).
Q I, as owner of Ne property. w nclusively contracting with IinnuA mnuaman b
CVNINeI the p,*a (Sec. 7014: BLLaIOGV ami PN(CSLOnf Code) The Commetnrs LI -
cense law does nom apply b an owner Of property who brills Or improves Nemon. and,
who commacu for such pmjcw with a cora (s) Raved pursuant w the Contractors
License taw.
❑Iver comom der See ,B&PCfmtbumamn
rte Com-- A_ Date , o
WORKER [NQS. ION DECLARATION
I bemby affrC ander pevlly (eajury ane Of Ne following declvtiov:
❑ Ihive willmainWna Cer riiosteofConscntwwlf-ivumfm WO sC=Nn-
ranitn, as provided for by Section 3700 Of the labor Cade, for the Performance of dw
work for which this Permit u issued.
❑ 1 have and will maintain Workers Compensation Insurann, ad impaired by Section
37W Of Ne labor Cede, for Ne peRommce ser the work for which Nu permit is issued.
My Workers Compmoatian Insurance carrier snd Policy number ane:
Cartier. Policy NO.:
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(rills wstlon need not br complcmd if the Permit is format hundred dollars (5100)
Or lest)
I sonify thin in to Performance of Ne work for which this Permit u issued, 1 shall not
eroplay,ny' person in any m ncyni�i to hegprnc subject w the Woken'Compcva0on
Low s of California, f)Ue 1 Il O
Applicant f ,Wan.
NOTICE TO APPLICANT. If, at 'ng this Ccnirica, of Escmpthat, you should
become subject w the, Workers Compensation Provisions of she Labor Code. you most
foMwiN comply with such provisions m this Permit shall br deemed mvokcd.
CONSm ON LENDING AGENCY
1 hereby alfrm than Vert i is a construction agency for the Performance of
use 3lending
the work for which thls permit u issued (Sec. 3097, Civ. C.)
b<odcrS Name
Add
Lendeh Address
1 comity that I haus read this application enol sum Wt the show infarmatiun u
1 agree w comply wide At city and county oNinvees and sum laws miming w
Wilding construction, and hereby mountain RprnCatatiVn Of thin City m enter Upon Ne
above-mentioned property for inspection purposes.
(We) agree w saw, indemnify ,cad kap hamlesn the City Of Cupertino against
liabilities, judgments. costa and expenses which may in any way accrue against said City
in consequence of the granting of this permlL
APPLICA,NT UNDERSTANDS AND WILL COMPLY WITH ALL NON -POINT
Issued by: Date
-
SOURCE
Re-roofs
Type Of Roof /
27io
Signature Applicum/Courtismaor Dam
HAZARDOUS MATERIALS DISCLOSUREmomhand
Wtll Ne applicant Wilding e. yore mandldm wmrial
oIMuni
Cham Hooldam
defined by Ne Cupenioo Municipal Code. Chapter 9.12, and Ne HnIN and Solely
. Section z55324)7
luno
All roofs shall be inspected nor [o an roofing material born installed.
P P y. g
y'.
❑Yes
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If a roof is installed without first obtaining an inspection, I agree to remove
Will caw applicant or future Wilding occupant use cqu mpeot of devpmo which
emit h unum.. air cowminanu as dcfired by the Bay Arta Air Quality Management
all new materials for inspection.
DuuleR
❑Yca No
1 haw read Ne himrdous mamrialsrcquiwmew under Chapter A95 Of the Collins.
nis Hcalrh & SelmyCade.Sectiwo 2550.25n3 w125534.I institutional Nanifthe Wilding
dorm Out currently haw a umanL Nu it u my responsibility w nctify Ne comment of the
requirements wines most x=I prior issuance Ofacm r.mOr a" --y.
Signature of Applicant Date
st 1011 V ( I '�
All roof coverings to be Class'" or better
I.
Dam
Owner or audwrissd agent Q