08100095 CITY OF CUPERTINO vidx'a, CY�v4 �A,
BUILDING DIVISION PEPMUT C®NTRAC _ R�INI�QRMATIOAi.f'-,'.
BU'LMTIE"S AN JUAN RD. ARTISAN BUILDERS � P08100095
ERR'SS NAME:: � — t'ERMTT ISSUE DATE
WM HALL 771 CLEMENTINA ST 10/16/2008
ONE: SANITARY NO. CONTROL NO.
(415) 863-2232
ARCHf1ECT/ENGINEER; - BUILDING PERMIT INFO
BLDG ELEC*r PLUMB MECH
0 0 0 0
uo0 LICENSED CONTRACTOR'S DECLARATION Job Description
U F 1 hereby alllren dui 1 am licensed under provisions of Chamer 9(commcrcing P
^z1!5d Mm section 7")ofDividen3ofthe Business and limfwiamChile.Slid mylke.0 KTCHN RMDL, MDFY CBNTS, ADD OPNING INTO LVRM &
w in full farce and tiff
�aM z
Z.On" Lt.M '�- ADD
-FOd Dam o. o C.U.Mor vi
Ey ARCHITECTS DECLARATION �t..Q_ MICROWAVE (115SQ)
iW8 1 understand my pedes stall m nerd ss public records
6
y o
t; Licensed Professional
5OWNER-BUILDER DECLARATION
X
1 hereby alarm mal 1 am exempt from the Com mrors License Law for me
❑O fallowing moron.(Section 1(u 1.5.Business and PmRisions Came:Any city or county
which requires a permit in cmmre:4 aimr,improve,dcmdish.or repair any structs m
priorb its issuance,abu requires Its,applicant for such permit to file a signed summon,
a
that he is licensed p oonsou m the provisions of de Convector;Licens Law(Chapmr 9 Sq.Ft,FIOo(Area Valuation
xy1-9 (commencing with Section 7")of Division 3 of then
Business ProfeuienCode)w $20000
ERR- dust Ie I,exempt Mandram and de basis for the Lleged co mpdan.Any violation of
Section 70313 by any applicant for.permit subjects the aPplknt m a Quil penalty or
not roam man fin hundmd dollars(5500). 3 4 217 0 8 9��Number Occupancy P Y Type
0 1,as own.of the property,army employers with wage u Meir sok compevadon,
will do the work-and She swctume is not manind or offered for sale(San.70/4,Business
and Professions Codm
c:The Comcors Licetsse Law data Out apm rtes.
ply an ,of Required Inspections
property who builds or improves tmrcon.and who dna sneh walk himself or through his
awn employees,provided that such impmwmen°are not intended araQareel forsale.If.
Insolent.me building or impromnent is sold within arc year ofcaupletion,the awer-
builde will haw,she border of proving mat m did ter Weld or improve for euryon of
sale.).
❑I.u owner of me Property,am excluAwly contracting with licensed condenars in
covuuct the project(Sec.7014.Business and PrefesJom Cade:)The Coavactw;Li.
comm Law does not apply to an owner of property who builds or improved demon,and.
who contracts for such pm*ta with a concrcmr(A licensed possession in she Contractors
License Law.
❑Isimmannin oder See ,BAPCformureasnn
nu Date
WORKERS COMPENSATION DECI.ARATION
1 hereby affirm under peulry of perjurym ofine follai ng declarecrosn
1 hart and will maintain•Ceriliamor Comem o calf-inure nor WerkeelCmmpcn-
lCarriev.
on,m provided fm by Section 37W of me Labor Code,for me Ntformance of the
k for which this petmit is indeed.
1 haw and will maintain Workers Compensation TnWrsnx,u required by Section
0 of the Mbar Cade,far me perform..of the work far which dent permit u issued
Workers Compenudme rthrr�ombi artier and Policy number am:
ST C T;'P O Policy No.:6 0 b b .
CERTIFICATE OF FXEMPrION FROM WORKERS
COMPENSATION INSURANCE
(Ihbmctlrm need an,In compmmd if the permit Is forone,hundred dollars($100)
nr Ian)
I cenif-v that in the performamc of the work for which this permit is issued.I shall mm
employ any person in any manner m is;In become subject to de Workers Compensation
Laws of California.Data
Applicam
NOTICE To APPLICANT:If,after mating this CeAneam of Exemption,you Should
beams,subject in the Wohers Compensbtion provisions of the labor Cade you am
.J O forthwith comply with such incremental or this pewnit Nall m deemed rewked.
Z "' CONSTRUCTION LENDING AGENCY
[-t 4 l hemby affirm them,dram is a construction leading agenry for the lerformance of
y> the work for which this Penna Is snood(Sec.3097,Civ.C.)
W Lenders Name
7 z Landers Addaess
U Q 1 certify that 1 haw read des application and Sum thin the above information IS
(p.^ corona 1 agree m comply with all city and county Ordinances and sum bars rtladng m
C)Cr.'! building construction,and hemby aumadae rtpmsenutivu of mu city in etmr open the
r abuw-mcotioawd Property for inspection purpoi
LL
(WS)agree to saw.indemnify and seep hamdm the City of Cupertino against
i (p liabilities.Judgments,cons and espouses;which may in any way amtm against mid City
fJ Z to comequcmc of the limmug of this hermit.
ti APPLICANT UN A DS AND WILL COMPLY WITH ALL NON-POINT
SOURCER
Issued by: Date -,&.--U '�
Re-roofs
Signuurt of can ntrecmr Dam
HAZARDOUS MATERIALS DISCLOSURE Type of Roof
Will the applicant or future Wilding Occupant stem mluadk hazardous material
deBmd by de Cupertino Municipal Cade.ChaPmr 9.1;and the Health and Safety
.setdensss3x(,)+ All roofs shall be inspected prior to any roofing material being installed.
❑Yes o
Will the applicant or future bending=Lmam um tyeipment or devices which If a roof is installed without first obtaining an inspection,I agree to remove
It houardnus Sir contaminants as defined by the Bay Area Air Quality Management all new materials for inspection.
DudictT
❑Ya flu
I haw rad the hvardtesmamriab m luvemmrts undcrChapmr 6.95 oftha Califm.
LHalm95afcty Cade.Srrions 15505.15573 amt ZSsl4.luMvssand mni[de bolding
e
tot cwm i,that It IS my re moreiaday in notify the occupant of the
mqulm esti re mor:toriormtssameof&Ce ricamafOceepatty. Signature of Applicant Date
or am&rind agent Dam
I° /L,o8,
Owner "
All roof coverings to be Class'A:i'or better
r