07100011 CITY OF CUPERTINO ` ° -p
,
BUILDING DIVISION PERMIT ���������'!"����������' ":
, . ;> ... ..-,.:
PERMIT NO.
BUILD , � r �g o,pR TIPTOE LA GRIDLEY COMPANY 07100011 .
11
PERMTT ISSUE DATE
OWNER'S NAME: ,
SARJEANT MARK P AND MAUREEN I 19 S 3RL� ST 10/01/2007
SANITARY NO. CONTROL NO.
NE:
(408)379-0900
BUILDING PERMIT INFO
ARCHI'['ECT/ENGINEER: BLDG ELECf PLUMB MECH
� o o c�
i p � LICENSED CONTRACT'OR'S DECLARATION JOb DeSCiIpIlO❑
; v� I hcreby afGrm Ihat I am liccnscd uadcr provisions of Chap�cr 9(commencing
;z� wiihScction7�U)o�Divisio of�hcBusincssandProFcssionsCodc.andmylicenseis REMODEL MSTR BATH & CLOST, HALL BATH & PANEL
�� y in full Corce and e!t � � 7�� �
�� z[.icensc Cl l.ic. � UPGRADE 2 O OAMP .
p Da�c Contracwr .� � /� � �
: � w A CHITECI'S DECLARATION
i a
a l undcrstanJ my plans shall be used as pubiic records
)yV
' u. �F„ Liccnscd PmCcssionai
: � a OW NER-BU►LDER DECLARATtON
�
1 hcrchy alTirm ihat 1 am cxcmpt trum �hc Coniractor's Liccnsc Law far thc
� p o Collowing mason. (Scction 7U31.5, Business and Profcssions Ca1c: Any city or rnunty
�,° � which requires a pertnit ta conswct, altcr. improvc, dcmolish, nr repair any stcuctucc
rior w ilc issuancc, alsu uires �hc a I�cant for such permit to filc a signcd swcmcnt Valuation
'_ Z} � � PP � Ft. Floor Area
a t h a i h c i s I i c c n s c J p u r s u a nt �o thc provisions nf thc Comrrcmr's licensc Law (Chaptcr 9 q' � 2 O O O 0
� t �(commencing wi�h Scction 7000) of Division 3 oC Ihc Busincss and Profcssions Codc) or
L�� that he is ezempt Ncrcfram and �he basis Cor the allegcd exempdon. Any violauon o[ Occupaney Type
Section 7031.5 by arry applicant for a pertnit subjects ihe applicant to a civil pcnalty of 3 5 9 3 2 0 5 E�!°'(�S1 Number
not more than fiw hundred dollars (5500).
❑ I, u owncr o[ tf�e property. ar my cmployces with wages az ihe'u solc compensation,
will do the work, and the suuauee is not intended or offered [or salc (Sec.7044. Busi�rcss Required Inspections
and Professions Codc: 'I'he Conuactors License Law do�� not aPP�Y w an o�*'"u °�
property v+ho builds or improves �hereon, and who daes such wort himselCor through his
own emplayces, providcd Wai such improvemenls arc not inten�d orotfered forsak_ It.
however, the building or improvemmt is sotd wiehin one year of complctian, tl�e owmer-
builder will have the burden ot proving t6at he did not build ar improvc for puryose af
salc.).
❑ I. as owner of the property. am exclusively conuuting wilh licenud rnnusctws W
construct the pcoject (Sec. 7044. Business and Professions Code:) The Contncmrs Li-
ccau [aw dacs not apply to an owner of properry who builds or improves Ihe�eon, and ,
who conuacts for such pmjecu with a coNractorts) Iicensed pursuant to the Conuactors
License Law.
❑ I am ezempt under Sec . B dc P C tor �his rcason
Owner Dale
WORKER'S COMPENSATTON DfiCLARATION
I 6ercby affirm under penalty of pepury one o( ihe falbwing declaralians:
❑ I hsve and will maintain a CeniGcate of Content lo sclf-insure for Worlrefs Compen-
sation, as provided far by Section 3700 of �he Labor Code, for Ne paformance oC �he
work far which Ihis pertnit is issued.
fv"I�I have and will maintain Worker's Compensation Insurance, as required by Section ,
�/00 oC �e Labor Code. Cw �he performance o[ the wortc for which �his permit is issued.
My Worker's Compensation Insucance cacricr and Policy number arc:
Cartiu: S'l?�f� �L� wJ 1� Policy No.: 7/ �lh'JC' Q� Y Z 3
CERTIFICATE OF EXEMPfION FROM WORKERS'
COMPENSAT[ON INSURANCE
(Chis secuon necd not bc complcted if We pecmit is for onc hundred doUars (5100)
or Icsa)
I cenify thxt in thc per(ormancc of �hc work for which U�is pccmit is issucd, t sY�all na
employ any persan in any manner so u to becomc abject w �he Workcrs Compcnsation
Laws of Califomia. Da�c
Applicanl
NOTICE TO APPC.ICAM: If, af�cr making Wis CeniCca�c of Exemp6on, you shoulJ
bccome subjcct to the Workcr's Campensaeion provisions of thc Latxx Codc, you must
�,`� forthwith comply with sueh provisions or this pccmit shall hc dcemcd revokcd.
z O CONSTRUCTION LENDWG AGENCY
[� r�-� I hcrehy alTirm thai thcre is x constcuction Icnding agcncy [or thc perCurtnar�cc u( .
(� � �hc wurk fur which this pecmit is issucd (Scc. 3097. Civ. C.) ,
W A Lendcr's Namc
� � C,cnder's Address
V � I ccrtiCy �hat I havc rcad this application and :ta�c �hat thc abovc infonnauon is
w � corrcct. 1 agrce to comply with all ciry and county onfina�es and state Iaws relaong to
0 U building conswction, and hcreby auchori�e represenwtivcs of this city to cnter upon Uic
� W above-meniioned propeny (or inspecuon purposes.
a (Wc) agrce to save, indemnify and kecp harmless ihc Ciiy o( Cupcnino against
�„E"",� � liabilitiu, judgmcn�s, cos�s and expenses which may in any way acccuc against said City
U z in consequence oC the granting of this permi� Date
� APPLICANT UNDERS7ANDS AND WILL COMPI.Y WITH ALL NON-POIN'f Issued by:
SO c�e� REGU NS.
�f� �1,,, �-�. i �j� �u 7 Re-roofs
s of ApplicanUCooiracar �'� T of R�of
HAZARDOUS MATERIALS DISCLOSURE YP
Will Ihc applicant or futurc building oaupant store or handlc harardous mau:rial
az defncd by �he Cupertino Municipal Codc. Chaptcr 9.t2, and the Hcalth and SaCcty
Calc. Scction 25532(a)? All roofs :�hall be inspected prior to any roofing material being installed.
� y� �No ,
Will ihc applicant or futurc building occupant usc equipmeM ar dcvices which
If a roof i:; installed without first obtaining an inspection, I agree to remove
emi� harardaus air conwminan�s as dcfincd by the Bay Arca Air Qualiry Mazugcmeni all new m aterials for inspection.
DisUict?
❑ Ycs [��
1 havc cca�i the ha�ardous matcrials requircmcnts undcr Chap�cr 6.95 of thc Califor-
nia Hcalih & Safcry Codc, Sections 25505.25533 anJ 25534.1 uncicrsiand thu if thc building
docs not curtcn�ly havc a tcnan4 �at it is my responsibiliry to noufy Um oocupant of �he
rcy' nuwhich us�bcmlpriorwissuanoeofaCcnificaico�a p���7 SignatureofApplicant Date
� pa � . All roof coverings to be Class "B' or better
Owncr authorizcd agcn�