07100122 CITI' OF CUPERTINO ` ` ` ` `
BUILDING DIVISION PERMIT ��������� ����������* �
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BUILDING ADDRESS: ' PFRMIT NO.
1184 BUBB RD WARD C�)NSTRUCTION 07100122 �
PERMIT ISSUE DATE
�R'S NAME:
vVASSON ROGER E AND LILLIAN H 5526 M��PLECREST CT 7 7
SANITARY NO. CON7ROL NO.
PHONE:
BUtLDINGPERMIT[NFO
ARCHITECT/ENGINEER:
REMODE_� KITCHEN & GUEST BAT B�� E[.ECf PLUMB MECH
O 0 � O
; o o LICENSED CONTRAC!'OR'S DECLARAT[ON JOU DOSCrlptl0❑
%�� I hcrcby aClirm Uiat I am licenscd undcr provisions af Chaptcr 9(commencing
; Z� wiih Scction 7000) of Division 3 of �hc Busincss and Pr ' n C o�. and m' is
�� y in full force and effec� �� .
� v� Z Licensc CIaSS Lic. S
: F , p Datc Contrxtor
!� ARCH[TECi'S DECLARAT�
j� a 1 undcrstand my plans shall be used as pub�ic rc
)yU
' a y Licensed Prt�fcssional
� y � OWNER-BUILDER DECLARATION
I hereby alfirm �hat I am excmpt Crom �hc Contractors l.icensc Law far itie
� p o following rcazon. (Scction 7b31.5, Busincss and Profacciont Codc: Any city ar coun�y
<,° E which requires a pertnit to conswc[, aiter. impmve. dcmolish, nr repair any strucwic
° Z y y, prior ui ils issuancc, also requires thc applicant for such permit to filc a signcd staicment Valuation
< �hat hc is liccnscd pursuant to �hc provisions oC �hc Canuacwr's Lic�cnsc Law (Quptu 9 Sq. Ft. Floor Area
r F� (commcncing wi�h Section 7000) of Division 3 oC ihc Busincss and Profcssions Cadc) or
i�° ihat he is exempt the�cfrom and the basis Cor the allegcd exempuon. Any viotation o(
Section 7031.3 by arry applicant tor a petmit subjccu U�e applicant w a civil paWty of APN Number Oecupancy Type
not more than five hundrcd dallars (5500).
❑ I, u owncr o[ tlie property, or my employcu with wages az the'v solc compensation,
will do thc wark, and ihe stcua�ue is notintendcd or oftercd (orsale (Sec. 704i. Busnw Required Inspections
and Professions Code: The Canuactar's Licenu Law docs nat appiy w an owner of
propeny who buitds a improves thercon, and wha does such work himselCor thcough 6is
own employccs. pro�ridcd ihat such improvements are not imended or allered [or �le. lf.
however, the building or improvement is sold within one year oC compledon,l6e owner-
builder will have �he burden oC proving tl�at he did not build or improvc [ar pmpose of
sale.).
❑ I. as awner of the property. am eacclusivety wnuuting with licensed conuactors w
construct �he pcojea (Sec. 7044. Business and Profcssions Cade:) The Contractors Li-
cense Law docs not apply w an ow�xr o( propeny who buiids or impro�ms ihe�. and .
who contracu tor such projects wi�h a con�ractor(s) Iicensed pursuant to ihe Convxtar's
License Law.
❑ I am exemp� under Sec , B& P C far ihis �euoa
. Date _.. _
WORKER'S COMPENSATION DECLARATION
I hercby afCim� under penalty o[ perj¢ry one o[ ttie following declan�i�aas:
❑ i have and will maimain a Ceni6cam of Conscnl lo xlf-insure for Workefs Canpen-
sation, as providcd fw by Section 3700 of the Labor Code, for the performance o[ the
wodc for which �his permit is issucd.
I havc and will maintain Worker's Compensation Insunnce, ac �cquircd by Scction .
o( thc Labor Codc. Cw thc performance of �he work for which U�is permit is issud.
My Worker's Compens Insuran e carticr and Policy number aze: /�
Carrier. �/ Policy No.: � �•/
ER7'(FlCA OF EXEMPI'ION FROM WORK RS'
COMPENSATION INSURANCE '
(ihis section necd.noc bc complcted if the permit is for onc hundred dollas (S1Q0)
or IcssJ �
I cenify ih.:t in thc performancc o( thc work for which U�is pertnit is issucd, 1 sbatl not �
employ any persan in any manncr so az to bccomc subject io �he Workcrs' Compcewuon
Laws of Cali(omia Da�c
Applicant
NOTICE TO APPL.ICANT: If, aftcr making this CcrtiCcatc of Excmptian, you shauki
become subject to �he Worker's Compensation provisions of the La6or Code, you muu
� O (oMwi�h comply with such provisions or this pecmi� shalt bc dccmcd mrokcd
Z "" CONSTRUCI'ION LENDING AGENCY
(. r�-� I hereby a[firtn that there is a consuuction Iending agenry Cor the performance of .
p�., � ihc wurk Cur which this permit is issucd (Scc. 3097, Civ. C.)
W� Q LendcPs Namc '
a z L.cnder's Address
V Q 1 cc�tiCY that 1 havc rcad this application and sta�c �hat U�c above inCamauon is
w � cortect. 1 agree to comply wi�h all city and county orJinances and staie laws celapng w
rJ- U building conswction, and hcrcby au[hori�e represcnutivcs of ihis city to cntcr upnn thc
� W ahovc-mcntioncd properly for inspccdon puqwses.
a (We) agrce to indcmni(y and kecp harmless �he City aC Cupertino agtintt
�� liabilitiu, judgmc , cos and expcnscs which may i y way accruc agains�said Gty
U z in consequerrc C the graating of Ihis permit.
�+ APPLICA UND R�'�'AND WILL PLY W ALL N -PO Issued by Date
SOURCE G ONS.
� � Re-roofs
Signuure f li r
HAZARDOUS MATER[ALS DISCLOSURE Type of R oof
Wi11 ppticant or futurc building occupant storc or handlc harardous matcria!
�c dc6ned by Ihe Cupenino Municipal Codc. Chaptcr 9.12. and thc Hcalth u�d Sa[ay
�, s�o� zssszca�� All roofs shall be inspected prior to any roofing material being installed.
❑ vu o
Will the applicant or fu rc building occupant use eyuipmcnl or devicrs which If a roof i s installed without first obtaining an inspection, I agree to remove -
cmi� harardous air contaminants as dcfincd by the Bay Arca Air Quality Managcment all new rr aterials for inspecr_ion.
Districc?
Q Ycs Nu
1 havc rcad �h ardcws maicrials requircmcn�s undcr Chaptcr 6.95 of ihe Califor-
nia Hcalth & Safct odc Sccuons 25505, 25533 and 25 . f undc d �haz iCihc building
docs nat curtent vc tcnan4 Ih '' y respo b' iry w ' y thc ant af
rcyuiremcn�s w' m bc met prior to i u a cnifi of Occu Signature of Applicant Date
� All roof coverings to be Class "B" or better
Owncr or aut i a t -