07100198 CITY OF CUPERTINO -
BUILDING DIVISION
PERMIT
PERMIT NO.
fff S AINSWORTH DR BROTHERS HOME IMPROVEMENT 07100198
.:R'S NAME: PERMIT ISSUE DATE
MARK & CRISTIN VAUGHAN 2510 DOUGLAS BLVD 10/29/2007
PHONE: (408)29' -0680 SANITARY NO, CONTROL NO.
ARCHITECT/ENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
O O` LICENSED CONTRACTOR'S DECLARATION
iu I hereby affirm that I am licensed under provisions of Chapter 9(commencing Job Description
z w with Section 70w)o!Division 3 of the Business and Professions Code,and my license is R ETR-F I'P WINDOW REPLACEMENT, LIKE FOR LIKE
' y in cult force and fleet. l� 900 9
t y? License Class Lic.8—aa'
t-w Date b Contractor r
ARCHITECTS DECLAR TION
wU I understand my plans shall be used as public records
-a
o Licensed Professional
y OWNER-BUILDER DECLARATION
j< I hereby affirm that I am exempt from the Contractors License Law for the
-00 following reason.(Section 7031.5,Business and Professions Code:Any city or county
which requires a permit to construct,alter,improve,demolish,or repair any structure
?z prior to its issuance,also requires the applicant for such permit to file a signed statement
=e` that he is licensed pursuant to the provisions of the Contractor's Litxnsc Law(Chapter 9 �;q.Ft.Floor Area Valuation
e (commencing with Section 7000)of Division 3 of the Business and Professions Code)or $14238
3 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 ]�Number I Occupancy Type
not more than five hundred dollars(5500). 3264600 -AIR D , v
0 I,as owner of the property,or my employees 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 Contractor's License Law does not apply to an owner of Required Inspections
property who builds or improves thereon,and who does such work himself or through his
own employees,provided that such improvements are not intended or offered for sale.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.).
0 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 so an owner of property who builds or improves thereon.and
who contracts for such projects with a contractor(s)licensed pursuant to the Contractor's
'tense Law.
am exempt under See. B&P C for this reason
..wner Date
WORKER'S COMPENSATION DECLARATION
I hereby affirm under penalty of perjury one of the following declarations:
0 I have and will maintain a Certificate of Consent to self-insure for Worker's Compen-
sation,as provided for by Section 3700 of the Labor Code,for the performance of the
work for which this permit is issued.
0 I 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 Insurance carrier and Policy number ate: ^�
Carrier: C Polity No,:
CEFICATE OF EXEMPTION FROM WORKERS'
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.I shall not
employ any person in any manncrso as to become subject to the Workers'Compensation
Laws of California.Dat^
Applicant
NOTICE TO APPLICANT:If,after making this Certificate of Exemption,you should
become subject to the Worker's Compensation provisions of the Labor Code,you must
Oforthwith comply with such provisions or this permit shall he deemed revoked.
z CONSTRUCTION LENDING AGENCY
(-�►+ I hereby affirm that there is a construction lending agency for the performance of
04 ✓' the work for which this permit is issued(Sec.3097,Civ.C.)
W Q Lender's Nam^
Z Lender's Address
U Q 1 certify that I have read this application and state that the above information is
W r. correct.I agree to comply with all city and county ordinances and state laws relating to
Ubuilding construction,and hereby authorise representatives of this city to enter upon the
Uabove-mentioned property for inspection purposes.
(We)agree to save,indemnify and keep harmless the City of Cupertino against
to liabilities,judgments,costs and expenses which may in any way accrue against said City ✓
U,Z in consequence of the granting of this permit.
"+ APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT Issued by: Date
;FE�g�ATI S. 16AVC Re-roofs Appiicant/Contractor Datc
HAZARDOUS MATERIALS DISCLOSURE Type of Roof
Will the applicant or future building occupant store or handle hazardous material
itned by the Cupertino Municipal Code,Chapter 9.12,and the Health and Safety
dc,Section 25532(a)?
❑Ya ❑No All roofs ;hall be inspected prior to any roofing material being installed.
Will the applicant or future building occupant use equipment or devices which If a roof i;installed without first obtaining an inspection,.1 agree to remove
emit hazardous air contaminants as defined by the Bay Area Air Quality Management all new materials for inspection.
District?
OYes No
I have read the hazardous materials requirements under Chapter 6.95 of the Califor-
nia Health&Safely Cade,Sections 25505,25533 and 25534.1 understand that if the building
does not currently have a tenant,that it is my responsibility to notify the occupant of the
require which muspo met 1rior to issuance Certificate of O�ccuupa�cyq Signature of Applicant Date
?r or authori�
9 agent '' ate— A]1 roof coverings to be Class"B"or better