08120107 CITY OF CUPERTINO T�. sax TQ�2" , Zl
BUILDING DIVISION PERT ��L!I
PERMIT
BUILDING ADDRESS: PERMIT NO.
19310 PRUNERIDGE AVE XL CON
OWNER'S NAME: PERMIT ISSUE DATE
O A CONTROL NO.
408) 271-2425
ARCHITECT/ENGINEER:
BUILDING PERMIT INFO
BLDG ELECT PLUMB - MECN
uOQ LICENSED CONTRACTOR'S DECLARATION
W 1 hereby am.that I am licensed under pmHsions of Cllaptw 9(commenting Job Description
ou withS &n7OM))of0ivuion3ofthc Code mylimmucis
_�N mfnnrnlaanderr Gr-t (LL411 COMM'L TI NON-RATED, NON-STRCTRL PARTN ,
�qz Lscense clan t.W.•
Dam ConloachorDECL WALLS/W(N)HARDWOOD FLR) NO E/M/P (1050 SQ)
e ARCHrTECTS DECLARATION
y�i 1 undersand my Plans shall W used as Public rtcorN
JyU
k0ln Licensed Professionala y 3 OWNER-BUILDER m Ce Contractors
Zoo hereby,(Sero on I con xempt from M Con nnaYf License Law for the
Zoo following reaaon.Permit
t 1871.5,BLLWho. and Pm,dcroli Code:Any oily tructucounty
$ which requires�a permit re cnnsWet.alter.inform,for Such
h Permit v or e a sig any taNelure
_Z< that he its�ensed ,a4um WOMt ensu s of for suchractur Lima Law(ed Srsmmcnt
that btttucdw�anlWthcorDiaimuorthe CantmcWfandPreelaw(LTodter9 Sq.FC Floor Area Valuation
Y�$ that he U exempt Sectionm and the
Division 3 of the B ooust pt on.Any
Code)or
Slat io u exempt any pp and un sena for the Subjects
LIalleged exemption Any I PUMIln of 0
Out
70313 w hurt red dollars;
runs permit subjeeu the applicant W a civil penally of APN Number Occupancy Type
tWt mom thsu Bw hundred Sonars(intro). p Y YP
01,as owner or the Property.or my employees with wages as their role compemsaker, 31606051 . 00
will De the work.and Use smcmre isnot smartest oronered for nude(Sec.' .Russ—
and
uss .and Pron fessioCode:The Conuaetofs U.Law don not apply W So owner of Required Inspections
property who builds or improve thereon,and who coca such work himself or through his
awn employees.provided steal such impmnmenm art not inmttded oroQered fm.rsle If.
hmw ,StebuildingwimMo wtusoldwithinaneyearofcompk6on.Steowner-
builder will have the burden of Proving that he did not build or impmvu for putyose of
sale.).
❑1,as owner of the property am ndu my conoaeting with licensed contractors in
construct the project(Sec.70",Business and Professions CodcU TLB Common's Li.
cense law don not apply he an owner of property who Wilds Or improves Ihemun,and,
who contracts for such prejeca with a comas ctar(s)licensed pursuant W the Gntrumfs
Li¢mse,law.
❑lamexemptmaha See .B&PCforthismamn
Owner Dam
WORKERS COMPENSATION DECLARATION
I hereby affirm under penalty of perjury one or the following declaratiwu:
❑1 have and will maintain aCutifinW of Camcnl W self-imam for Worlams Camper,
sation,as provided for by Section 3100 of Sc Labor Code.for Ne perfa maws of the
work for which this Permit is issued.
❑I have and will maintain Worker's Compensation Insurance,as required by Scetion
3100 of Ne labor Code,for Ne pedormanee Or the work for which this permit is issued.
My WmIUe..,Cy Pe So huurancecartierand Polic,numberare:
Gnic -a++ policy No.:5 SO
CERTIFICATE OFEXEMPnON FROM Wo KER RII
COMPENSATION INSURANCE
(nm sectile need no,be canpleted if the .it Is forone hundred dollars(5100)
or less.)
1 certify that in the performance of the work for which this Permit is issued,1 shall not
employ anyperson in my manrersu as W become subject W Ih WorWn'CompensaSan
Laws of Califiand.Dam
Applicant
NOTICE TO APPLICANT:IL after making this Certificate,of Eacmption,you should
become suhjem W the WorkCs Compeesstion provisions of the Tabor Code,you muq
.J .z forthwith comply with such Provisions or this Permit shall be dcemed revoked.
ZO CONSTRUCTION LENDING AGENCY
[--�► I hereby wrim OatScre u a connotation lending agency for the Pcdormanm of
E
the work for which this crout is issued(Sec.3097,Civ.C.)
Q lenders Namc
z Lobbes Address
C.J Q 1 testify that 1 have read this application and slate thal Ne above ulf.mtatiun u
Iy F corresv 1 agree In comply with all city and county ordinances and Stam laws relating to
_0 U Wilding construction.and hereby authodm repmsemadims of this city to enter upon the
abme-mentioned property for inspection purposes.
C (We)agree to save,indemnify and keep harmless the City of Cupertino against
fn liabilities,judgments,cosu and expenses which may in any way accrue agaltut said City
U z eco nce of the granting of this permit.
CA NDER NDS AND WILL COMPLY WITH ALL NON-POINT Issued by: Date
OURCE REG O �Z
Re-roofs
Signal dApplicanJContracmr aW
HAZARDOUS MA AIS OISCL URE Type of Roof
Will the applicant or run=Wilding ausmrew aadle harardon material
s dcftned by the Cupertino Municipy'Eode.Chafe, ,and Sc Health and Safety
Cade, 0YO,3551i(a)? X14/ All roofs shall be inspected prior to any roofing material being installed.
❑Yea o
Will the applicant or fusurt bel g amvpanl use equipment ar dcvim which If a roof is installed without first obtaining an inspection,I agree to remove
emll havaNnus air conlaminanls as tncd by Ne Bay Ahm Air Quality Management all new materials for inspection.
Du cs7
❑Yes 711.
1 have mad the hwarJom materials requiremcnla under Ch2ph06.9SorLc cater.
nia Health&Safety Cade.Sai=u M5,M513am 534.1undcrsmndthmiftW building
does note y W truant-that it u my respmuibility W testify Sc ace rant of Ne
mqm rola m 'ar W iMaanm ora caurcaW arOctap Signature of Applicant Date
r I
Own rautham<d agent DaW All roof coverings to be Class'�a'or better
"