07080096 CIT�' OF CUPERTINO '' ` ' 1�� �
BUILDING DIVISION PERMIT ���k� ����� ������`�'����
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PERMIT NO.
BUfLD �� ApA � RES B s bLLINGER RD TBD — TO BE DETERMINED 0 7 0 8 0 0 9 6 •
U
! PERMIT LSSUE DATE
.R'S NAME:
JAMIN HE 10 12 2007
SANITARY NO. CONTROL NO.
PHONE:
BUILDING PERMIT INFO
ARCHIT'ECI'/ENGiNEER:
BLDG ELECT PLUMB MECH
� L� � �
i p o LICENSED COM'RAC7'OR'S DECLARATION JOU DCSCTll]I1011
: V� I hcrcby affirm that I am licenscd undcr provisions aC Chaptcr 9(commencine
; Z� wi�h Sccdon 7000) af Division 3 oC ihc Busincss and Profcssions Codc and my Iicensc is 7 9 2 S Q F T ADD - FAM I LY RM K I TC H EN , UT I L I TY RM � PORC H �
�< a in full foree and effect . /� '7 76 I
j�? LicenscC �Lic.A �� BAYWIN�OW/REMODEL MASTERMEDRM, ROOM ALTERATION.
: E , � Datc I D' Z— 2�'�!'� 7 Conuactor Q- CDf1 �'
� ARCHITEC['S DECLARATiON
i a Q I undcrstand my plans shall Ac uscd as public rccords
>aU
° u. y Licensed Profcssional
� y � OWNER-BUILDER DECLAt1AT10N
1 hcrcby alfirm that 1 am cxcmpt Crom ihc Contranor's Liccnsc Law for thc
� p O lollowing reason. (SccGon 7i131.5, Business and Profcssions Caic: Any eity or counry
�,°, � which rcquires a pertnit ro conswct, altcr, improve, dcmolish, or mpair any suucturc
° Z� prior w ils issuancc, alsu rcquires thc applicant for such permit to filc a signed suicmcn� , FL. FIOOI' AI'e3 Valuation
-< that hc is IiccnscJ punuan� �o thc pmvisions o[ Uu Conuactur's Liccnsc Law (C6aptcr 9 '�q $171514
�' F� (commencing with Section 7000) of Division 3 of Ihe Business and Professians Code) or
y�� that he is exempt the�cfrom and tlK basis (or tAe allcged eacempuan. Any violazion o[
Section 703I.5 by a�ry applicant for a permit subjecu ihe applicant w a civit penalty of p R]� Number Oeeupancy Type
noi mom man r�c hu�drca douacs (ssoo). 3 S 9 2 3 O 2 H L
❑ I, u owncr oC ttie proputy, or my employces with wages as their sole compensa�lon,
willdo�hework,andihesuun�ueisnotintendedorefferedforsale(SecJ Required Inspections
and Professions Code: The Conuactar's License Law does not apply w an owner of
propeny who builds or improves thereon, and who does such work himseltor through his
own employces. providcd that such improvements are not intended or ottered for sala If.
hawever, the building or improvement is sotd within a�e year oC compleuon, tl�e owner-
builder will have the burden oC proving Uwt hc did not build ar improvc tor pu�pose of
salc.).
❑ I, as awner o( �he propeny, am exclusively conuac�ing wi�h limnsed rnnvx�ors w
const�vct the projea (Sec. 7044. Business and ProCessions Cade:) Tt�e Contrxturs Li•
ccnse Law docs oot apply to an owner af propeny who builds or improves the�eon, and .
who contracts tor such projects wi�h a con�ractorts) licenzed pursuant to �he Convactor's
License Law.
^ I am exempt under Sec. . B� P C tor this rcuon
_ Date _.. -
WORKIIt'S COMPENSA'I70N DECLARA170N
I hercby afficm under penalty of perjury onc ot the following declarauons:
❑ I hsve and will mainuin a Cuti6cam of Consent to setf-insure for Worlcer's Compen-
sation, as providcd for by Sectian 3700 of the Labor Code, for the performanoc of �
wo�ic for which ihis pertnit is issucd.
❑ I havc and will maintain Worker's Compensation Insurance, as rcyuired by Section
3700 oC We Labor Code. Cor the pcA'ormance of the work for which this peimit is issued.
My Warke�s CompensaGon Insucancc cartier and Policy number azc:
Carrier. Policy No.:
CERTIFICATE OF EXEMPI'[ON FROM WORKERS'
COMPENSATION INSURANCE �
(fhis sec[ion necd not bc complcteJ if the permit is for onc hundred dollars (S1fl0)
or less.)
I cenify that in thc performancc of U�c work for which �his pertnit is issucd, l shall not
esploy any person in any manner so ac to become mbject �a the Workers' Compensatian
Laws of Cali(omia Date
Applicant
NOTICE TO APPLICAM: If, afmr making �is CcNtiwtc of Excmptian, you should
become subject to the Worker's CompensaUon provisions of U�c Labor Code. you must
, O foMwith comply with such provisions or this permit shaU be dcemcd n.wakcd.
z ""' CONSTRUCTION LENDING AGENCY
(�-�r r�-� I hereby alTirm U�at there is a constcvction Iending agency far Uu per[ormance of .
p; � ihc wurk Cur wAich ihis pertnit is issucd (Scc. 3097, Civ. C.)
W Q Lcndcr's Narnc
� z L.ender's Address
V � 1 ccrtifY Iha� 1 havc rcad this application and siatc Ihat �hc abovc info�mauun is
w � cortcct. I ageee to comply with all ciry and county aretinances and sta�e laws ccladng W
� U building conswction, and hereby authome reprcsentativcs of this city to cntcr u�n lAc
� W abovc-mcntioncd property (or inspccuon purposes.
a (Wc) agree to save, indcmni(y and kecp harmless the City of Cupcnino against
H � liabilitiu, judgmcn�s, cos�s and expenscs which may in any way accruc against said City /� //
V z in consequcncc oC thc granting of Ihis permil. D3Ie �V�l ('��
� APPLICAN'C UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT Issued by
SOURCE REGULATIO
�vl�z /.� � Re-roofs ��'
Signawrc of Applican onuxtor �a� T e of R oof
HAZARDOUS MATERIALS DISCLOSURE YP
Wi11 thc appliant or futurc building acupant smre or handlc ha�ardaus maocrial
'cfincd by the Cupenino Municipal Codc. Chaptcr 9.12. and the Health and Safety
�. SccGon 25532(a)? All roofs shall be inspected prior to any roofing material being installed.
�y� ❑No .
Will thc applicant or futurc building occupant usc cquipmcnl or dcvices which
If a roof is installed without first obtaining an inspection, I agree to remove
emit harardous air contaminan�s as defincd by the Bay Arca Air Quality Managcment all new rr aterials for inspection.
asu����
❑ Ycs ❑ Nu
1 havc reaJ the hvardcws matcrials requircmcn�s undcr Chap�cr 6.95 of Uu Califor
nia Hcal�h & SafetyCode, Secuans 25505.25533 a�u125534.1 mderstand thatiFtl�c building
docs not curtcntly havc a tcnan4 �at it ic my responsibility w noufy thc cecupant of �hc
rcyuircmcn�s �u��,�arac��;r�a�oro��r. SignatureofApplicant Date
� � Z- All roof coverings to be Class "B" or better
Owncr or a orizcd agcn� Datc -