08110015 CITY OF CUPERTINO +-•-:�+�+ .T�.a•sx:, � d�' a� `.
BUILDING DIVISION PERMIT 7RCONTRA T�aRgI1VIf'a,_ 1�'I�AT'P
BUILDING ADDRESS: PERMIT NO.
10111 CRESCENT CT LOT 3 TBD - T
OWNER'S NAME: PERMIT ISSUE DATE
WEp A CONTROL NO.
ARCHITECTIENGINEER: BURRING PERMIT INFO
BLDG ELECT PLUMB - MECH
UOO LICENSED CONTRACTOR'S DECLARATION
in� 1 hreby allirm that 1 am listened d under ptlons of Chapter 9(cammencmng Job Description
with Section 7(1111)of Division 3 of Ne Busirmasand Professions Code.end my license is
�2„ I.full CONVRT PART OF EXTNG GARG TO A PLAY RM & A
ynZ Licmac Class Lin.a
—� Date Contractor STORG(266SQ) 7 NO STRUCTURL
ARCHITECTS DECLARATION
1 understand my plans mail h used as public meet&
U
g O I7 Licensed Professional
OWNER-BUILDER DECLARATION
I hereby affirm that I am exempt from the Contmmor't License law for the
00 following mason.(Section 10315,Business and Protrusion Code:Any city Of county
<5 8! which remains a permit to eonuuct,alter.moisture.demolish,or repair any l4um ere
taxi prior as is issuance.also requifn the applicant for such permit to rile a signed sumunt
ESG Natkis littered pufruanttothe provismmsofthe CommeterilucneLaw(Chaptm9 Sq.FL Floor Area Valuation
at— (canmcncing with Section 7000)of Division 3 Of lh Business and Piefnasian Code)or
y $ that he is comp(therefrom and the beds fee th 91c cul...mpti0n Any violation of 1 0000
Sectmm 70315 by arty applicant(o a Permit ubjx �applicant m a civil wallya APN Number Occupancy Type
nn..Nan Bra bmtdred dollars($SW). P Y YP
❑1.as owns of the property.or my uvployco with wages as their sole cOmpemamn. 3261709 . 02
will dodo work and the structure u.1 intended or offered for sale(Sec.7014,Bummus
and Pred.donna Code:The Contractor's License law dos ooh apply to sm owam of Required Inspections
property who Wilchimimpows thereon,and whodoessuch work himselforthrough his
own cmpboyon,provided that such improvemen are not intended mattered formic.U.
omc m.the building or improvement is said within oro year of completion.the owner-
Wilder will buss the burden of provin5 that he did eat bound or improve for purpose 0f.'
said.). //
❑I.as Owner of the property,am utlusively contracting with licensed conttaa3ors to
concoct the,project(Sec.7044.Business and Profession Code:)The Conn i:tm'.Li.
cone law don not apply to an owner of properly who Wilds or impmsssiheaon,and
who contracts for such pmjccu with a conwmor(s)licensed pursuanm the Contractor's
License Law.
❑1 am cmaap a .B k P C for Nis mason
OweDau
ke
i WORKER'S OMPENSA'E TIONDECLARATION
I hemby affirm under penalty of perjtuy oncof the following declamation:
❑1 has and will msintaln aCutiOuteof Conent lo self-inaurt foworkds Compem
radon.as provided fan by Serio.3700 of the labor Code.for the yafformano of the
wank for which this permit is issued
❑I have and will maintain Worker's Compensation Irtmvance,as required by Section
3M the labor Code.for Ne performances,ofdte work fon which this Permit u issued. '
My Woreces Compensation Leamo nce carrian and Policy number art:
Carrier. Policy Na.:
CERTIFICATE OF EXEMPTION FROM WORKERS
COMPENSATION INSURANCE
(This section teed not h completed B the permmt is for me hundred dollars($100)
or tea)
1 certify that in the peffo....of the woa for which Nis permit is Wood,l shall nm
employ any punas.in any oanorm as an become subject to de Workers'Compensation
Law s of Califom'a, te
APPlicutt -1
NOTICE TO APIWKXANP.If,sour making this Ce.ilicate of Exemption,you should .
become subject as the Worker's Compcnatim provision of the Labor Code,you most
O forthwith romply with such po,wobs o Nu Permit shall h decmeA mokcd.
Z^ CONSTRUCTION LENDING AGENCY
F he.by thertuacunlfu.3097. r.agenry fon ole performance Of
.0.ei Z the wart Na which the Permit V issued(Sec.3(19'f,Or.G)
Dz tender's Name -
z alder's Addnu
U Q 1 certify that I base rend this application and sate than the abuse information is
Ii.F eanteet I agrte m comply with all city and county ordinnaes and state Ian Hating to
0 U Wilding concoction.and hereby udomim rtprnutatim of this city to cotta upon(
[T7 above-motioned property fon inpection Purposes
4 (We)agree to urn.indemnify and keep hasmins the City of Cupertino against
r'/1 liabilities judgmcnu,costs and espeosn which may in any way aecfue agarol said City
U Z in emeregtencc of the granting of this permit. p// / jr
^ APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT Issued by: Date h 7 /t
SOURCE REGULA
n Re-roofs
SignaturcofA - ommelor Dam �Z.
HAZARDOUS MATERIALS DISCLOSURE Type of Roof
Will Ne applicant m future Wilding ecnPantslom an handle hummucus material
as defined by the C.,Nno Municipal Code.Chapter 9.13.and the Health and Safety
Code.section 255324)7 �Na All roofs shall be inspected prior to any roofing material being installed.pro
41 Will Ne applicant of forum Wilding occupant art equipment Or device,which If a roof is installed without first obtaining an inspection,I agree to remove
..it havardon A,cmuminantt as dcOncd by the Bay A.Air Quality Managcmem all new materials for inspection.
Distrbct7
❑Yet o
I here mati the basardoos maarialsrequvemcw under Chapter 6.95 of ft CAifo.
oma Hcalthd:SafctyCodc,Savors 235(15,35533 and 25534.I unMsmuid thalifte building
Joos rel currently base a tenant.Nu its my responsibility m oddly the asupant Of th
require menutw OR met or c ofaUnirinmafa�a y. Signature of Applicant Date
OwAll roof coverings to be Class'%?"or better
k/ono and steel Dam' '