07100131 CITX OF CUPERTINO f � <. ': � ` y � , � '
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BUILDING DIV1S10N PERMIT 4��������.4 Z����Y��T���:+` :
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eutc.n i x �� q �� ES � , ARALLONE DR TBD — TJ BE DETERMINED P 07100131
.JER'S NAME: PERMIT LSSUE DATE
CALVERT M S AND DIANE K 10/18/2007
PHONE: SANTTARY NO. CONTROL NO.
ARCHIT'ECT/ENGiNEER: BUILDING PERM►TINFO
BLDG EI.ECT PLUMB MECH
� O p LICENSED CONfRAC7'OR'S DECLARAT[ON � O � �
� V� I hcrcby aCfirm that I am liccnscd ondcr provisions oCChap�cr 9(commencing Job Description
: z� with Scction 7000) of Divisian 3 of ihc Businegs and Profcssiuns Codc and my liccnsc is 6 NEW W I NDOWS & 1 NEW DOOR IIV EX S TNG O PEN I NG S
�� y in full Corce and e(fec�
� � ? Licensc Class Lic. #
: F i p Datc Contraclor
,a ARCHITECI'S DECLARATION
�� U 1 undcrstand my plans shall bc uxd at public rccords
. c.
: 0 y Licensed Profcssional
� y � OWNEA-BUtLDER DECLARATION
j a� 1 hcrcby a(Grm �ha� I am czcmpt Crom ihc Contracrors Liccnsc Law far ihc
� p O Collowing rcason. (Sccuon 703I.5, Busincss and Profacsians Cak: Any ciry or county
�,°, � which requires a pertnit to canswct, al�cr, improve, dcmoliah, or repair any suucwre
° Z} prior 4� iLt issuancc, also rcquires �hc applicant for such permit to filc a signcd suicmcnt
�_ � ihat hc is licenscd pursuant to ihc provisions o( thc Contracwr's Li��cnsc Law (Chaptcr 9 :;q. Ft. Floor Area $ Valuation
� F (commencing wi�h Section 7000) of Division 3 of ihe Businesc and Professions Code) or 12 � � Q
y 3•• that he is ezemp� therefrom and IAe basis Cor the allegcd exempdon. Any violation of
Section 7031.3 Ay a�ry applicant [or a pem�it subjects the applicant to a civii penalty of � Number �CCU 8I1C T e
not more chan five 6undred dollan (5500� 3 6 9 3 9 0 3., �� P Y YP
❑ I, az owncr oC tl�e property, or my employces with wages u their solc compensation,
will do thc work and �he strunum is aot intended a ofCered for sa:c (Scc. 7044, Business
and Pmfessions Code: The Canuxwr's Licenu Law docs �rot apply to an owner of Required Inspections
property who 6uilds w improves Wercon, and who dces such wort himsel[or thcough Ais
own employces, providcd that such improvemen�s are no[ inandeA or otLered for sala If.
however, the building or improvement is soid within one year of compieuon. �he owner-
builder wil! have the burdm of proving �hat he did not build or improvc (or puryax of
sak.).
I, u owner o( the property. am acclusively contracting wi�h licensed mnuxtors w
Uie projea (Sec. 7044. Business and ProCcssions Code:) 7}ie Cootracror's Li-
cense Caw docs aot appiy w an owner of �nnpeny who builds or improves Wemon, and ,
who conuacu for such projecls wiU� a contrutor(s) Iiansed pursuant to �he Convactars
L"uense Law.
I am ezemp du , H& P C far n
_.� ���� Da� l0 I�
��� WORKER'S COMPENSATION DECLARA770N - • _
I hercby �rta under penalry of pe�jury onc of the following declaratians:
❑ I hsae and will maintain a CertiGcate of Conscnt to self-insucc for Worker's Compen-
sation, as providcd for by Secdon 3700 of the Labor Code, for the pcdormancc of �he
work for whicd Ihis pertnit is issucd.
❑ I have and will maintain Workefs Compensation Insunncc, ac �cquired hy Scction
3700 0( thc Labor Codc, for thc per(ormance of 1he work for which this permit is issued. '
My Worker's Compensation Insurancc carticr and Policy numbcr azc:
Cartier. Poliry No.:
CERTIF[CATE OF EXEMP170N FROM WORKERS'
COMPENSA'f[ON INSURANCE
(Chis scc6on necd not bc completcd if the permit is for onc hundred doltazs (S 100)
or Icss.) ,
i cenify �hai in thc perforn�ancc of Ihc wo [w qhich �his pertni� is issucd, 1 slwll not
employ any person in any manncr m m 'ect ta the Workcrs' Compensatlon
Laws of Califom'
Applicant
NOTICE TO A : lf, a r malcing ihis Ccrtificatc of ExcmpGon, you should
bccome subjcct ta �hc Workcr's Compee�auon provisions of �c Labor Codc, you muu
� O forthwith comply with such provisions or [his permil shall bc dccmcd revokcd.
z � CONSfRUCTION LENDING AGENCY
F+ �—+ I hemby af[irm Uut there is a consuuctinn Iending agency for the performance of
(Y, ? Ihe work for which this pertnit is issucd (Scc:. 3097, Civ. CJ �
W� Q C.endcr's Namc
� z Lcnders Address
() � 1 certifY �hat 1 havc rcad ihis application and sutc that thc abovc into�matiun is
��-'� cortect. 1 agrce �o comply with all city and counry onlinances and suic laws mlating to
rJ U building conswction, and hereby authori�e �cprcscniativcs of ihis city to cnter upnn the �
� a ahove-mcntioncd property (or inspcction purposes.
(Wc) agrcc to save, indcmni(y and kecp harmleu �hc City of Cupertino against
H� liabiliuu, judgmcnts, costs and expenses which may in any way accruc against said City
(} z in consequence oC the grandng of this permit. /� j�
"'" APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POIIYf Issued by: Date � �
SOURCE �y LATI �
_�G�/,� �� /'6 //f 0 7 Re-roofs �_/'
Signuurc of�pphcanUContractor ate '
HAZARDOUS MATERIALS DISCLOSURE Type of Ro� �f
WiII Ihe applicant or futurc building accupant uorc or handle ha•rardous matcrial
iefincd by thc Cupenino Municipal Codc. Chaptcr 9.12, and thc Hcal�h and Safety
.��� Section 25532(a)? All roofs st all be inspected prior to any roofing material being installed.
❑ Ycs �No '
w��i u,� a ����,� o� ���� �,��a�� occu ant usc If a roof is ; nstalled without firsi obtaining an inspection, I agree to remove
pp g p cyuipmcnt or dcvices which
emii harardous air contaminants az dcfincd by the Bay Area Air Quality Managcmcnt all new mat erials for inspecr.ion.
Districc?
❑ Ycs �
_/
I havc rcaJ the hvardcws'matcrials rcquiremcnts undcr Chaptcr 6.95 of �he Califor-
nia Hcal�h & Safcry Cadc. Scctions 25505, 25533 and 25534. t undcrs�vid ihat iC ihe 6uilding
docs not currcntly havc a Ihat it is my responsibiliry w noufy �hc occ t of thc
rcyui w h m mel pri usuance of a Ccnificatc of .
`Q'��� � w A � D � � Signature o:'Applicant Date
v � - All roof coverin s to be Class "B" or beiter
Owncr or authori agrnt Datc g