08100151 CITY OF CUPERTINO
BUILDING DIVISION PERMIT COI ORM' " TWO
BURRING ADDRESS: PERMIT N0.
803 CANDT.FWOOT) DR TBD TO RF pFTFRMTNRn opi onj C;1
OWNER'S NAME: PERMIT ISSUE DATE
dqk-
CONTROL NO.
ARCHf1ECffFNGINEER: BUILDING PERMIT INFO
BLDG EfECT PLUMB MECH
MOO LICENSED CONDIACTOWS DECLARATION Job Description
1 horsey affirm Ow 0
that I acatsed under provisions of Chapter 9(commencing p
with Section 70kB or Division 3 ofthe Busimao and Profession,Code,and my Iketee is
�F in run sera and erten, RMDL MSTR BTH(50SQ) ,CONVRT (E)BTH TO WLKIN CLST,
inn License Class Lis.11
e-r-o Dam Comhacmr ADD LAUNDRY CLST &ADD CLSTS FOR STDYRM &
ARCHy lb
ATION
I uMeraund my plans shall bcusas used publiDECLAc rec«ds HALLWY(100SQ)
JyU
k LLo Liceomd Professional ,
OWNER-BUILDE0.DECLARATION
.�<y I hereby affirm that 1 am exempt from tW Contranah License Law for the
02 following mason.(Section NO I.S.Business and Profession,Coda:Any city On county
3 �+ which onto.•permit m cnruva4 than.improve.demdlsh,err repair any summers.
Zi Prior so its issuance.also requirns the,applicant for such permit in file Isigmad statement
< We he is licensed pursuant tothe provisions;ofNcContmcmrat;«meLaw(Chapmr9 Sq.Ft. Floor Area Valuation
(commencing with Samoan 7000)dDivision 3 ofma Business sort Profesiom Code).,
`<
that W is exempt Netefrom and the basis for the alleged exemption.Any violation of
Section 7031.5 by any applicant fora permit subjects the applicant to a civil pmulty of APN Number Occupancy
rot came than five hundred dollars ane($500). P Y Type
❑I,aowtvl Of Ok pmlw+tY•«my wplayceswiN wage aOmvsole campensaOon, 36918021. 00
will dO the work and tW structure Is not intended On Offered fors tic(Soc.7044,Business
and Pmrexslam Code:The Contemner License Law does tet appy to an saner of - Required Inspections
property who Wilds«improves damean,and who dassuchw«khroselfon through his
own employees,provided Nat such improvements and not intended«offered for sale If.
however,the building or improvement u sold within ane year of ampleti s.the owner-
builder will have tW buds of proving that he did Out hold or improve for purpose of
sale.).
0 1,u Owner of the property,an esclusivelr contracting with licensed aaeanos to
=me=Ne pmjem(Sec.7044,Business and Professions Code:)The Comeaenes Li.
cmue law does not apply to an owner of property who Wilds or impmves demon.ad,
who contracts far such p.jems with a canuamer(s)licensed possuant to the ConmsuYs
License law.
0 lameaemptunderSee ,B&PCfartlusean
so
,^
Owner ( �� —
DECLARATION
41 I hereby aRsm under pandly of perjary,one of the following dalaavian,:
0 I h.ve and wBl maintain•Catifiesu ofCon,ent n self-sown,f«Workers Compere
salon,u provided f«by Samson 3700 of the labor Code.fm the perfomtame mf one
wart far which Nu pcmtit is issued.
❑1 have and will maintain Workers Compensation Insurance,as requited by Section
3700 of the Taber Code,far the pufman.of Ne work for which this permit u Issued.
My Workers Compevsa in,Wunnce carrier and Policy number are:
Canner. Policy No.:
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(This asset.need Out W completed blithe permit u f«oa herndaddoliars(21007
or lat
1 catify Net in the perrarma«c of Ne waste far which our permit is broad.I slWl nm
employ any person in any manner w as to Wm embj«Ie the Workers Compensation
Laws of California Data
C ,7—j ate_
APPllcma
NOTICE TO APP ANT:If.Often making this Cenilicak of Exemption,you should
become subject m Ne Worker's Compeesdtion provisions of tic labor Code you am
0 O forthwith comply with such provisions or this permit sir
pee]W damm
ned olted.
Z y CONSTRUCTION LENDING AGENCY
[—t I Waeby affirm that Nem is a cotutmction lendingagetay for Oe Performance of
D: > die work ser which this permit Ir issued(See 3097,Civ.C.)
!A Landers Nance
Z Lenders Address ,
U O 1 mstify that 1 larva now this applimuicn and sum flu the.rove information is
W rcompact-I as=to comply with all city and county an inames and sone laws misting u
OU Wilding csttswction.and botchywthatlm mpmsaufiM of(WIMLY to enerupmm the
W shove-mantiond property for inmemion purposes
6, (We)agree to save.indemnify and keep harmless the City of Cupertino against
to liabilities,judgments.toxo ad expenses which may In soy way acave against said Cy
V in consequence of the granting of this permit
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT Issued by: &azz_ Date G 2 -r-c�G.
Data
HAZARDOUS
MATERIALS DISCLOSURE Type of Roof
Will the applicant«future Wilding a.Chapter
r 9.1 or handle hamth sued
material
u dsRned by the Cupertino Municipal Cade.�tapur 9.11,and the Health and safety
Cents,Secedes zss3z(.7T All roofs shall be inspected prior to any roofing material being installed.
Oyes QJ10
If a roof is installed without first obtaining an inspection,I agree to remove
Will the applicant or aurum Wilding by Occupant B me equipment or Mara which g
Dist haadnus air anumin,nu a dcOned by ties Bay Arta Air Quality Management all new materials for inspection.
District?
❑Yea ON.
I have mad the haadmus materials requirements under Chapter 6.95 of the Califon,
.is Health&Safety[ode.Scouts 15505.15533 and 15534.1 understand!Jest ifthe Wilding
dos net cvmendy have a mnmL Out It 4 my respan,ibility m testify the«eupant of the
requlmmenuwhkhmmtWmetpmwwt uwceof•Cmtiftcatcaf Occup cy.
Signature of Applicant Dale
' ass