08110087 CITY OF CUPERTINO
BUILDING DIVISION PERMIT �- PINFORMATION g
1,oONTRACTO•rkv'a��' "�..;.:;".. ,�;ter
BUILDING ADDRESS: PERMIT NO.
10350 S DE ANZA BLVD H H CON TR
ER'S NAME: PERMIT ISSUE DATE
E;RRY HOUSE 149 9R;4SSE]oS ST
PHONE..- SA CONTROL NO.
ARCHITECT/ENGINEFR:
BUILDING PERMIT INFO
INSTL BLWR ON TOP WALL IN BLDG EIECI' PLUMB MECH
u�
LICENSED CONIRACMICSDECLARATION COOLR EXTNG RESTRNT& vnprtvfc l� O l� O
rd0 I hereby affirm Nat l am licensed under provisions of Chapter 9(commencing ,)BeSCr]pllOn
;¢ wiNScaion?W)of Division30fthc Busiwaaand Profeu(onsC d md.yfitconsis
< In full rater'Nd GR
j LICCnae GI. '
r Date f comaow
ARCHITECTS DECLARATION
'416 1 unden and my Plans shall be used as public records
C.
g G Licensed P urclommil
3 OWNER-BUILDER DECLARATION
<i N I hereby afire that 1 am exempt from the Contractor's License Law for the
no fallowing mason.(Section 7131.5,Business and PrefossinO Cade:Any city or county
which Oquires a permit.Consruct,alter improve,demmLah,or Oran,any snetum
°i pd.,W its onumot.also mquima WC applicant for such Permit to file a signed statement
<
Won Wislicensed pursua LWWepmvisimuofWCConuazmislicemelaw(Chartter9 Sq.FC Floor Area Valuation
x€S (commencing with Scetion 70DO)or Division 3 of the B usiness and Pm'-'O-Or
y -
that he is exempt thcmfrem and We basis for the alleged Gaempd.n.Any violation of
SGCOon 70313 by any applicant for a permit subjects the applicant m a civil penalty of APN Number Occupancy Type
not mart dun five hundred dollars(M). P Y YP
❑I.u owner of the property.m my uoployw with wages n thea sole eanpewdan,
will do the war.and the$net.is not inched aro@md for sale(Sat.70",Business Required Inspections
and Pretreatment Cons:The Com nceYs License Law does not apply a e ns an owner of q p
propeny who builds Or import.therrnn.i ndwho doesauchwork himself.,though his
ownomplayeex,Provided snot such improvements we notim ended ornQe,ed formic.If.
however,We building or improvement U mid within oro year of eompkdon.We owner,
builder will have Ile burden of poving that he did not build Or improve for purpose of
Rale.).
0 1,as M.of the Property ae acludvcly contracting with licensed camatms on
wnsmma the papa(Sec.7014,Business and Profmat rs Code:)The Complicates U.
cense law does Out apply in an owner of property who builds or improves Woman.roa.
who convects for such propos with a compactor(s)licensed pursuant in the Comm tor's
License Law.
❑Iameaempunder See ,B&PCrorddareamn
Dole
WORKER'S COMPENSATION DECLARATION
1 hereby afliam under Penalty of perjury one of the fallowing declarations:
01 hamand w01 mainWn a Cadfteamafcoman to self-insure for Worker's Compere
sarion,n provided for by Eaton.371)).1 the labor code.far the Performance of We
wor for which this Permit is issued.
0 1 have and will eainuin Worker's Compensatrue Insurance,as neforod by SCNon
37M of the Labor Coda,far the pd....of UO wart for which this permit u issued '
My Worker's Compensariw Wunna ars roti Policy number art:
Grier, Policy No.: b O
GER'IFlGATE FEX Pf1C FROM WOyftRERS' �_
COMPENSA ON INSURANCE
facia secdm oed wtb.eomplemd if 0te permit u fmaw hundred d.Ban(3100)
or kis)
I certify that in We performance,of the work for which this Permit is issued.I shall not
employ any Person in my ma mcrso is to become subject in the Workers Compensation
Laws Of California-Date
Applicant
NOTICE TO APPLICANT:If,after making this Ccoifiam of Exemption,you should
become macs to We Waters Compensation previsions of We labor Code,you mw
O foMwith Comply will such pmvidom Or this permit shall be deemed revoked.
Z"" CONSTRUCTION LENDING AGENCY
[-t 14 1 hereby allinn that there its coaskai
uon lending agency for the Md..of
Q't ti the war for which this permit is issued(Sec.3097,Civ,C.)
GQ Under's Name
z Iandn's Md.
U C) I costly that 1 have read Win application and sure oat We above information or
V,P toren.I agrm in comply with all city and county ordinances and sum laws rolating us
0 U building consuuc0.n,and hereby amnoriM mpmxnoniveS of this city to toter upon We
ahow-aphationcd property for impaction purposes
y (We)agree to Rave.indemnify and kcep harelan the City of Cupertino against
'A limiliomjudgec.ts,casu and expcaua which may in my way aacun against said City
in eo
menta of We granting of this permit.
-- APPLNT uEA os AND ILL coLL Noo r� Issued by: Date �� —n.7 GC�
SOU E ULATIOFV
,L_ // /
T�'� 17fRe-roofs
Signature ofAppli a uactml f Date
HAZAltDOdS MATERIALS DISCLOSURE Type of Roof
Will We applicant or forme building occupant smm or Wndlc haardous eamdal
defined by the Cupertino Municipal Cade,Chapter 9.13,and We Health and Safety
.Section 25532(a)? All roofs shall be inspected prior to any roofing material being installed.
C3 Y. �Na
Will the applicant or future building Occupant um equipment or devices which If a roof is installed without first obtaining an inspection,I agree to remove
emit hazardous air Contaminants as defined by We Bay Arta Air Quality Management all new materials for inspection.
Oisuics7 �`1"'
Oyerk.
vc mad the hvaMau_materials mquiremems under CIOWOO6.95 of the Califor-
niaHe �wh
Cade,Se um 255115,2553 25534.I undersand Wad iftic building
does n ime a¢ l at II u my pas hility m notify the oceupant m
mgmro mx .rte m .f.cmfcate.ro' max Signature of Applicant Date
IL v.'
Owner ter autharimd a m Duty'
All roof coverings to be Class in!'or better