07100018 CIT�' OF CUPERTINO ' `
BUILDiNG DIVISION PERMIT ���'k�.A��� I��'���ATIOI�'; ;
, ,;:
, .:.<.
PERMIT NO.
BUILDING ADDRESS:
20091 LA RODA T _ T�
P RMIT LSS DA
'�R'S NAME:
S . CONTROL IVO.
PHONE:
BUILDING PERMIT INFO
ARCHI7BCClENGTNEER:
BLDG ELEC7 PLUMB MECH
� � 0 0
> Q LICENSED CONTRACTOR'S DECLARATION JOb D2SCfl�7t10❑
� F I hcrcby afficm that I am liccnscd undcr provisions ot Chaptcr 9(commcncing
:� with Scction 7000) of Division 3 of Ihc Busincss and Profcssions Codc, and my liccnsc is
� y in full force and cffec� REMODEL MSTR SUITE � KITCHEN � BTHRMS � REROOF � RELOCTE
; ? Licensc C1ats Lic. #
: o p cooiraMOr FURNACE & WTR HTR
ARCHI'IECI'S DECLARATION
'-� f undcrstand my plans shall hc uscd as public rccorJs
'e
. � Liccnscd Prufcssional
� a OWNER-BUILDER DECLARATION
��
I hcrcby afGrm that 1 am cxcmp� from chc Contractors Liccnsc Law for ihc
j O following rsacon. (Scction 7031.5, Business and Profcssions Codc: Any ci�y ar county
g� which requi�rs a pcm�it to conswc4 alter, improve, demolixh, ar repair any swcturc
; y N, prior ui ils iscuancc, also rcquircs thc applicant (or such permit to filc a signcd sutcmcn� �' q . Ft. Floor Area Valuation
-< t h a t h c i s l i c c n s c d p u c s u a nt to thc pmvisions of thc Contractor's Li�tnsc Law (Chaptcr 9 �
Cp
�(commcncing wi�h Section 7000) o( Division 3 of lhc Busincst and Profcssions Codc) or
;.. that he is ezempl Ncccfrom and tAe buis for the allegcd eumption. Any violaGon o[
Section 7031.5 by a�ry applicant for a permit subjccts �he applicant to a civil penalty of APN Number ccupancy Type
not more �an five hundred dollars (5500).
❑ I, as owncr o[ the property� or my employces with wages u their solc compensadon, 3 6 9 3 4 0 3). 0 0
willdothework,andihestcuctureisnotintendedorafteredfarsalc(Sa. Required Inspections
end Pro(cssions Code: The Conuactor's License Law does not apply to an owner of
property who builds or improves thereon, and who does such work himsel( or through his
own employces, providcd tha� such improvements are not intendeA or oCfereA for sale. I[.
however, �he building or improvement is sold within one year oC complcao�, the owner-
builder will have the burden of proving tt�at he did not build or improve tor purpose of
salc.).
�.I as owner of �he property, am cxclusivcly contracting wilh liccnsed rnnvactors to
�Oastruct the projea (Sec. 7044. Business and Protessions Code:) The Conuac�or's Li•
ccnse Law does not apply to an owner of propeny who builds or improves 16ereon, and ,
who contrac�s for such projects with a conuactor(s) licensed pursuant to the Convactor's
License La
� 1 am un e'" nder S , B& P C f r this on
v.r �JOx v�
� WOR 'S COMPENSATION DfiCLARATION
I hercby affirtn under penalty of perjury one a( the following declarauons:
❑ I hsae and will maintain a Cenif catc of Consent lo self-insure Cor Workcr's Compen-
sation, u provided for by Sation 3700 of the Cabor Code. for ihe performance o( �hc
wo�k (or which this pertnit is issucd.
❑ I havc and will maimain Wwkcr's CompensaUan Insurana, az mquired by Scction
3700 oC the Labor Code, Cor the pedormance oC �he work for which this permit is iuued.
My Workers CompensaGon Insucancc cacricr and Poliry number are:
Cartier. Policy No.:
CERTIFICATE OF EXEMP770N FROM WORKERS'
COMPENSATION INSURANCE �
(ihis section need not be completed i( the pertnit is for ane hundred dotlazs (S 100)
or Icss.)
I cenify that in thc performancc of thc work for which this pertnit is issucd, 1 shall not
e�nploy any perso " y manner become subjecl to the Workers' Compensation
Laws of Califo a a
Applicant � � � �/ .
NOl'10E TO AP CAM: If, aflcr making this Cenificate of Excmption, you should
become subject to the Worker s Compensadon provisions of ihe [.aAor Code, you must
� O forthwith comply with such provisions or this permit shall Dc dccmcd revokcd.
i
""' CONSfRUCT10N LENDING AGENCY
�►�-� I herchy affirm Ihat thcre is a consuuction knding agcncy Cor thc performaMx uf
;� Uic work (or which �his permit is issucd (Scc. 3097, Civ. C.)
� Q L.ender's Name �
� z L.cnder's Address
)
) � 1 cenify U�at 1 have rcad this application and siate that the ebove informauun is
�" cmrec� I agmx to comply with all city and county orclinances and sute laws rclating w
j v building consuuction, and hc�tby authoria representativcs of ihis city to cntcr u{xin thc
+ W atavc-mcnuoned prvpcnyforinspecuon purFwses
y a (Wc) agrce to save, indcmni(y and kecp harmless ihc City of Cupcnino against
�� liabiliuu, judgmcn�, costs and expenses which may in any way accrue agains� said City
) z in consequence aC the granting o[ this permit. Date
�"^ APPLI UNDERSCANDS AND WILL COMPLY WITH ALL NON-POINT Issued by: �� "`� 1 / ��
SO CE e� ULATI
ln.�� �v � � Re-roofs '��
Sign ofApplicanUCo tor �� • I • y�C Of R��f
HAZARDOUS MATERIALS DISCLOSURE
Will �he applicant or fuiwc building occupant storc or Aandlc ha•rardous ma�crial
�c dcfincd by the Cupenino Municipal Codc. Cltaptcr 9.12, and �he Hcalth and Safcty
��, Secdon 25532(a)? All roofs : hall be inspected prior to any roofing material being installed.
❑ Ycs �'No
�� If a roof i� installed without first obtaining an inspection, I agree to remove
Will thc applicant or fuwrc building accupant usc cquipmcnt or dcvices which
cmit harardous air contaminan�s u dcfincd by thc Say Area Air Quality Managcmcnt all new m; ►terials for inspecr.ion.
District? �
O Y� °
1 havc rcad lhe ha�ardous ma�crials requircmcnts undcr Chapicr 6.95 of �hc Califor-
nia Hcal�h & Safcry Codc, Scctions 25505.25533 and 25534. I undcrstand Ihat iC ihc building
docs not c nAy havc a tcnant, �hat it is my rcsponsibility to noufy thc occupant of tt�c
rc uircmc hich m priorw issuance ota Ccnificatc o� cupzn Signature �f Applicant Date
�� All roof coverings to be Class "B" or better
Owncr �authori�rdagcnl Da�c �