08120067 CITY OF CUPERTINO
BUILDING DIVISION PERMITCoC�PTQW
BUILDING ADDRESS: PERMIT NO.
10142 E ESTATES TBD –
W NER'S NAME: PERMrr SSU DATE
O SA "2908CONTROL N0.
ARCH=/ENGINEER:
BUILDING PERMIT INFO
BL00 ELELT PLUMB MECH
REMODEL 49 S FT OF MASTER O O O O
goo LICENSED COMA(M)R'S DECLARATION BATH NON–STRUCTURAL Job Description
1 hereby affirm that 1 am licensed under plovis ous of Chapter 9(commmminv
with Sl%uon]QTV)ofD n3ofdo,BLL9neV red PmreaSONGOde,andmylleCM1CY
In fnlI Inns and eneeL O
Jura LicennClass fY.M '
^q Osm Comnnar
r CHITECTSDECIARATION
U I arWerstend my plans¢hall W used as public records
oG Licensed Prufcs must
3OWNER-BUILDER DECLARATION
ny 1 Wrthy eRrm that I am exempt from me Contractor's License Law for me
E p 0following reason.(Section 7031.5.BLLa1M3a and Plefetiom Cock:Any city or county
which ngWm•a permit to cnnurnel ohm.iminum.demolish,m mpah any swcsu e
iy prior in its ivuucs.auto mquim the applicant for such permit to rile a signed stamment
FFss`o that bei,licensed puran,ntmthe provisions ofthe cwttraemrauecnmLaw(Chapter 9 Sq.Ft. Floor Area Valuation
YF$ (commencing with Section 7000)of Division Jnfthe Business and Prafessiaas Code)or
^ that he is exempt themfmm and Om basis for me alleged eaempdon.Any violation of
Section 7031.5 by any appncanl far a pcOnh wb*M rhe applicant o a Civil penalty of APN Number Occupancy Type
tech mart dun fivehurWmd mlWs(SSW).
❑L as awnes of me thepmy,w my wpl nded.I h Magas as theh M.wmpenvne
will m thework utathe suumumuran.Licensaset.dea ft Out a(Sec.]04x,Businesso
end property
Wilds Cede:TTe mthacon. ndwho law dna net apptio if w owner ase Required Inspections
propertywhopro i impmw thereon,endwho doesouchwork himwt(wtlwugh his
ownemployes,providedman Such improvementsaxe not intendedoraRmed rise Natalia.If.
however,the have
us,
ea imPm proving sold within arc year of completion,the owner
builder vW Nve me When of proving Out K did deli Wild w impure(w PurPns<of
sok.).
❑1,as Owner of the Property,am exclusively contracting with licensed mnaecu rs to
construct the pmjew(Sec.]OW,Business and Profession Code:)The Comracmts Li-
came Law dos not apply in in another of luopcny woo builds or improves mernew.and
who camense s for wed projects wide•eondamorm)licensed pursuant in do Convxmr'a
Lima.Law.
I am exempt under Set ,B&P C far this reason
canerDECLARDam
WORKERS COMPENSATION ATION
1 hereby¢fide under lineally of perjery arc of me following declarations
I have and will maintain a Certificate ofCmuenuo se)(Assune forWorker's Compen.
no=.as Mvided far by Section 3700 of dm Lebec Code,far the performance of the
were for which this permit is issued
❑1 hive and will maintain Wwkds Consternation Imwuhce,as m itmil by Section _
31W M me Labor Code.far the puformwee of the wart far which due permits issues.
My Worker's Compemauan lnsunn amity std Poliryntur, am:
Carrier. Paltry Na.: (f�OO/���Y�
CERTIMCATEOFEK MONFROMWORKERS'
COMPENSATION INSURANCE
(Thissecdon need vel W camplemd time permhis forcer nmmwmllus($I W)
or lura.)
I certify that in me perforreanec of me,work for which this permit is issued.l shell not
canploy anypc..in any Owner w as m become abject o the Workers'Compevatia t
Laws of Caltfamit Data
Applicant
NOTICE TO APPLICANT:If.arta making this Certificate of Exemption,you should
become subject to the Winters Compensation provia ins of the Labor Cade,you roup
O forthwith MMpiy wide Such provisions w this permit shall he domed naked.
Z C7 CONSTRUCTION LENDING AGENCY
F, IWreby¢R.dor mart isaeemtruninn kndlagagercy far the performance of
ax > do wan far which rots N.It B named(sec.3097,Cir.C.) .
QLander'.Name
lender's Address
V 0 I Certify that I have read this application and sum that the above infohmation is
Uy ^. correct.l agree to comity with all chy and county oNicatm and sum laws rtlaung o
.O kS.^l Wildtngcortamuclian.nod hereby Sermon.representatives of this city m cater pon dM
W ahove-mentioned pmperty for inspection purposes
(We)agree to Save.indemnify nod keep hamkss the City of Cupertino against
jl liabilities judgmcnta.cam and cSpcnsas which they in any way aa.govt Said City
V z in corn o grantingof thisr
pem it.
APP LIC U ERSTANDS ANDWILL CO PLY TH ALL N N-POINT Issued by: Date
U TI
SOUR ONS.
a ��6�� Re-roofs
sin
g HAZARDOUS MATERLAIS DISCLOSURE �— Type of Roof /
Will the is Culmol or future Wilding arupantsmm or and the
luncheons material
as defined by the Cupertino Municipal Code.Chapter 9.11,and die HNN and Safety
PSection 25532(a)1 All roofs shall be inspected prior to any roofing material being installed.
❑Ym Ly No
call the applicant or future branding occupant use equipment or devices which If a roof is installed without first obtaining an inspection,I agree to remove
P
emit haudi em air conuminints a defined by the Bay Area Air Quality Management all new materials for inspection.
District] IQ
—
0Ym XI No `�
I have real the heSan1/muTmucrirts mquiremcnts under Cnvpmr6.95 of the cation.
.is Health&SafctyCole,Sections 15505.25537 and 25534.I understand this if f Wilding
M0,have a uncal Wt it u my repo mufy de occupant of the
chmusWmetpdorinssuaccofaCard of oaa Signature of Applicant Date
w tom>rdagcnl in All roof coverings to be Class'1W'or better