07090098 CIT�' OF CUPERTINO ` ' �`'� D
BUILDING DIV1S10N PERMIT ����"'���'�"���������• '
_..
PERMIT NO.
BU1LD1 c, DDRESS:
1�U�367 HENEY CREEK PL TBD — T� BE DETERMINED 07090098 �
PERMTf LSSUE DATE
R'S NAME: .
STEVE DAUBER 10 11 2007
— SANTfARY NO. CONTROL NO.
PHONE:
BUIGDING PERMIT INFO
ARCHITECT/ENGiNEER: BLDG ELEGT PLUMB MECH
� 0 � �
� p o LICENSED CON7RAGTOR'S DECLARATION JOb DeSCilptlOil
: V r ( hcccyy �rm that I am Iiccnscd unJcr provisions o[ Chaptcr 9(rnmmcncing
; z� with Scction 7000) of Division 3 of thc Busincss a�d Profcssians d my liccnsc is PV S 0 LA R AT tZ'J � F T 0 P � F EX I S T I NG S F D.
;� y in full focce and ef(ect
� � � Licensc Class �M• �
; F p Datc �� Contracmr
�!� ARCHITECI'S DECLA A
j�< 1 undcrstand my plans shall be used as public records
)yV
' u. y Liccnsed Profcssional
: a e OWNER-BUILDER DECLARATION
�
1 hcrcby alTirm �hat 1 am cxcmpt Crom ihc Con�raaors [.iccnsc Law or thc
� p o [ollowing rcason. (Scction 7031.5, Busincss and Profccsions Caic: Any city or county
�° � which rcquires a permit to conswct, altcr. improve, dcmolich, or rep�ir any suucture
U" y prior W ils issuancc, alsu rcquires �hc applicant for such permit �o filc a signed sta�cmcnt ��, Ft. Floor Area Valuation
; z< thai he is liccnsc d pursuan t to t hc p rovi s i o n s o( t h c C o n v x t u r' s L i�� c n s c l aw ( C ha ptcr 9 �� q
r F� (commencing wi�h Section 7000) of Division 3 af Ihe Business and Professions Cade) or $ 5 5 5 7
i�� ihat he is ezemp� therefrom md the basis for the alleged exempUon. Any violauon of Oceupancy Type
SecUon 7031.3 by azry applicant Cor a permit subjec�s ihe applicant to a civil penalty of 3 4 2 4 8 0 2 7� Number
not more ihan fivc hundrad dollars (SS00).
❑ I, as owner of tl�e properry, or my employces witN wagu as the'v solc compensauon,
will do thc woric. and the swctuse is not intended or offered for sale (Sec. 7044. Business Required Inspections
and Professions Cade: The Conuactors Lianse Law docs noe apply w an owner a(
propeny who bui►ds or improves thercon, and who does such work himself ar tlwugh his
own employccs. Providcd that such improvements are not imendeA or o[tered (or rala l[.
however, the building or impmvement is sold within one yesr of complction, the ownerv
builder will have the burden oC proving �6at he did not build or improvc far purpos� af
sale.).
❑ I, as owner o[ �he property, am ezclusively conuuting wi�h Iicensed conuac�ors w
constnut Ne pcoject (Sec. 7044. Business and Professions Code:) The Convactors Li-
ccnse Caw daes not apply w an owncr of property who builds or improves �he�eon, and ,
who convacts Car such projects with a conuactot{s) licensed pursuant to the Canvac[ars
License Law.
r"' T am exempt undu Sec . B& P C[or this rcason
.r Date _.. -
WORKER'S COMPF.PISATION DECLARATION
I heroby attirm under penalty o[ pe�jury one of �he follawing declarations:
hsve and will maintain a Cenificate o[ Consent to self-insure for Workc�s Compen-
sation, as provided for by Section 3700 of the Labor Code, for the perfarmar�cc at �trc
work for which Ihis permit is issucd.
❑ I have and will maintain Warker's Compensation Insunna, as �equired by Scction .
3700 oC �hc Labor Codc, Cor thc performance o[ the work for which this permit is issued.
My Workers Compensation Insurancc carricr and Poticy numbcr arc:
Carrier. Policy No.:
CERTIFICATE OF EXEMPl70N FROM WORKERS' ,
COMPHNSATlON INSURANCE
(This section necd not bc complcted iC the permit is for onc hundred dollazs (E 100) .
or Icss.)
1 certiN thxt in thc performancc of Wc work for which ihis permil is issucd, I shall not
cmploy any person in any man� �al,�oh�enR wbject �o �he Worlcers' Compensation -
Laws of Califop�if. "� - — ��' � -
Applicant _ �Y ,,..� .
NOTICE I'O AYPU�nNT: If, aftcr making �Ais CcniCcatc of ExcmpGon, you should
bccome subject to ihc Workcr's Compcnsation piovisions of Uic Laboc Codc, you must
�,`� forthwith comply wilh such provisions or [his permit shall bc dccmcd revokcd.
Z O CONSfRUCT10N LENDING AGENCY
(...� ►-. 1 hemhy affirm that there is a consuuction knding a�cncy for thc performancc uf -
GY, � ihe work Cur which this pecmit is issued (Scc. 3097, Civ. C.) ,
fsl A Lendcr's Namc '
a z L,ender's Address
V � ( cenifY �hat I have rcad �his application and state lhat �he above infonnalion is
�� cortect. 1 agcee to comply with all city and county oreiinances and sta�e laws relating to
rJ U 6vilding conswetion, and hereby authori�e representa�ivu of this cily to cnter upon thc
� W abovc-mcntioncd property (or inspccuon purpoxs.
a (Wc) agrce to save, indcmni(y and kecp hartnless the Ciiy of Cupcnino against
H � liabilitia, judgmcnLS, cos�s and ezpcnscs which may in any way acccuc agains� said City
U z in consequcnce aC t6c granting of ihis permit. l` �
►� APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT Issued by: Date ��i �/
SOU REGULATIO iS /�
`7'�1 �� Re-roofs ,�--
Signaw o IicanUContractor �� Datc
HAZARDOUS MATERIALS DISCLOSURE Type of F.00f
Will ihe applicant ar future building accupant store or handlc harardous material
'cIIncd by �hc Cupenino Municipal Codc. Chaptcr 9.12. and thc Hcal�h and SaCcty
:. Scction 25532(a)? All roofs shali be inspected prior to any roofing material being installed.
❑ Ycs ❑ No .
Will the applicant or futurc building occupant use eyuipmcnt or devices which
If a roof is installed without first obtaining an inspection, I agree to remove
cmii haxazdnus air contaminants as dcfincd by the Bay Area Air Quality Management all new n�aterials for inspection.
DisvictQYcs 4y'�
1 havc read �he ha�ardenis maoerials requirementc under Chap�er 6.95 a(the Cali(or-
nia Hcalih & Satcty Codc, Scctions 25505, 25533 and 25534. f undcrstand �hat iCthc building
docs no� curtcn�ly havc a �cnant, Ihat i� is my respantiAility to noufy thc occopanc af �hc
rcyu' n�s which must met p' � uancc oCa Ccnific tc of Ocs�pe� Signature of Applicant Date
All roof coverings to be Class "B" or better
Owncr or a i•r.cd agc ���