07060079CITY OF CUPERTINO
BUILDING DIVISION PERMIT '��!l'{R
PERMIT NO.
BulLnlrMT DRIANA AVE ALLBRAND WINDOWS 0 7060079
23312 CABOT BLVD 06/11/2007
PHOryF_ - SANITARY NO. CONTROL NO.
(650)622-0330
ARCHITECT/ENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
°C LICENSED CONTRACTOR'S DECLARATION
p O
or g 1 hereby affirm that I am licensed under provisions of Chapter 9 (commencing
Z with Section 7000) of Division 3 of the Business and Profcasioas Code, and my license isM y in full fora and effect i
Z License Class Lk. p
F Date Contractor
ARCHrr=S DECLARATION
I understand my plans shall be used as public records
,yU
U. Licensed Professional
:0 ; OWNER -BUILDER DECLARATION
I hereby affirm that I am exempt from the Contractors License Law for the
: a O following reason. (Section 7031.5, Business and Professions Code: Any city or county
i m � which requires a permit to construct. alter, improve. demolish, or repair any structure
prior to its issuance, also requires the applicant for such permit to flc a signed .,area t
xe that be is licensed pursuant to the provisionsof the Contractor's License Law (Chapter 9
(commencing with Section 7000) of Division 3 of the Business and Professions Code) or
that he is exempt therefrom and the basis for the alleged exemption. Any violation of
Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of
not more than five hundred dollars (S500).
❑ I, as owner of the property, or my employers with wages as their sole compensation,
will do the work and the structure is not intended or offered for sale (Sec.7044. Business
and Professions Code: The Conuactor's License Law does not apply to an owner of
property who builds or improves thereon, and who does such work himself or duoogh his
own employees, provided that such improvements are not intended or offered for We. if,
however, the building or improvement Is sold within one year of completion, the owner.
builder will have the burden of proving that he did not build or improve for purpose of
sale.).
❑ 1, as owner of the property, am exclusively contracting with licensed contractors to
construct the project (Sec. 7044. Business and Professions Code:) The Contractor's Li-
cense Law does not apply to an owner of property who builds or improves thereon, and .
who contracts for such projects with a coauactor(s) licensed pursuant to the Contractor's
Dense Law.
❑ 1 am exempt under Sec , B & P C for this reason
Owner Date
WORKER'S COMPENSATION DECLARATION
I hereby affirm under penalty of perjury one of the following declarations.
❑ I hsve and will maintain a Certificate of Consent to self -insure for Warkees Compen-
sation, as provided for by Section 3700 of the Labor Code, for the performance of the
work for which this permit is issued.
N1 have and will maintain Worker's Compensation Insurance, as required by Section
3700 of the Labor Code, for the performance of the work for which this permit is issued.
My Workers Compensation Insurancecarrier and Policy number are:
Carrier.?/_.+•Tr! 114 5— C. Policy No.:Zoggg C-? (
CERTIFICATE OF EXEMPTION FROM RKERS'
COMPENSATION INSURANCE
(this section need not be completed if the permit is for one hundred dollars ($100)
or less.)
I certify that in the performance of the work for which this permit is issued, 1 shall not
employ any person in any manner so as to become subject to the Workers' Compensation
Laws of California. Date
Applicant
NOTICE TO APPLICANT: If, after making this Certificate of Exemption you should
become subject to the Workers Compensation provisions of the Labor Code, you must
Z forthwith comply with such provisions or this permit shall be deemed revoked.
Z O CONSTRUCTION LENDING AGENCY
.�
F-r � I hereby affirm that them is a mnstnscton lending agency for the performance of
.� the work for which this permit is issued (Sec. 3097, Civ. C.)
CWn Q Lenders Name
Z Lenders Address
U 0 1 certify that I have read this application and state that the above information is
w — cortecL I agree to comply with all city and county ordinances and state laws relating to
0 U building construction, and hereby authorize representatives of this city to enter upon the
U above -mentioned property for inspection purposes.
a City
(We) agree to save, indemnify and keep harmless the of Cupertino against
Hrn liabilities, judgments, costs and expenses which may in any way accrue against said City
U Z inconsequence of the granting of this permit.
APPLICANT UNDERSTANDS AND LL COMPLY WITH Ail, NON -POINT
SOURCE R
MATERIALS DISCLOSURE
Will the applicant or future building occupant store orhand)c hazardous material
as defined by the Cupertino Municipal Code. Chapter 9.12. and the Health and Safety
Cock, Section 25532(a)? �
C] Yes
Yes Li�
Will the applicant or future building occupant use equipment or devices which
emit hazardous air contaminants as damned by the Bay Area Air Quality Management
District?
C] Yes
I have mad the hazardous matoria)z requirements under Chapter 6.95 of the Califor-
nia Health & Safety Code, Sections 25505. 25533 and 25534.1 understand that if the building
does not currently
Occupancy. 7
Owner or authorized aecnt D
Job Description
WINDOW REPLACEMENT 14 RETROFIT, 1 NF W/WALL CUT
DOWN TO LOWER WINDOW SILL, 1 SLIDING DOOR
Sq. Ft. Floor Area
32620027My Number
Issued by:
Re -roofs
Type of Roof
SS�1
Required Inspections
Occupancy "lype
Date
All roofs shall be inspected prior to any roofing material being installed.
If a roof is installed without first obtaining an inspection, I agree to remove
all new materials for inspection.
Signature of Applicant
Date
All roof coverings to be Class "B" or better