07080027 CITY OF CUPERTINO �������������'����fi :
BUILDING DIVISION PERMIT
PERMIT NO.
�BU�L10275�ANTHONY PL CLINT BjTNCH CONSTRUCTION 07080027 .
pERMTT LSSUE DATE
�ER NAME: � 11 / 0 6/ 2 0 0 7
LEE JAMES M AND BETTY M 16860 J�)LEEN WAY STE 3
SANI7'ARY NO. CONTROL NO.
PHONE: �L�08� 7'7g-0330
BUILDINC PERMiTINFO
ARCHI'IECC/ENGINEER: BLDG ELECT PLUMB MECH
�� 0 � �
� p � LICENSED CONTRAC7nR'S DECLARA7'ION JOb DeSCfIPtlOil
� V C 1 dcrcby aflirm �hat I am licenacd umlcr provisions oC Chapur 9(commcncing
_�� aith secrion 7000) of oi�ision 3 of thc Business and Prokssiore Codc. and my licensc is C OVERED PAT I 0 W/ BAR , F I RE P LAC E, WOODF I RED
�� y in ful l Coree an d e f tect. � 8� ���__, OV E N 4 9 2 ��
� � Licensc Clats L�. x �
� F, � Datc � ( ^ ��_ Conlracwr
AKCHITECI'S DECLARA770N
�� t 1 undcrstand my plans shall bc uscd as public rcco�ds
w
�
; u. y Licensed Profcssional
: � e OWNER-BUILDER DECLARA'CION
� �� I hcrcby afGrm �hat 1 am excmp� Gum ihc Contractars Licensc Law for thc
y p O following icason. (Scction 7(Y31.5, Busincss and Pro[cssions Codc: My city or caunty
.� ,°, � which rcquims a pcfmit w conswc4 a���. �Pro``°� �molixh, cv repair any swcwre Valuation
'� ^ y prior in i�s iuuance, also requims �hC applicant (or such pertnit to file a signed stalemcnt S Ft. Floor Area
—^< t hat h e is li ce n s c d p u rs u s n t t o t h c p� o v� s i o n s o f t h c C o nuacwr's Li�ronsc I�w (Chap�cr 9 9• $10 5 4 7 0
� t �(commencing wi�h Scction 7000) of Division 3 of ihc Busincss and Profcuions Codc) ur
y�� thu he is exempt the�efrom and the buis Cor the allcgcd exempdon. Any violation o[ �CCU SI1C T e
Section 7031.5 by azry aPPlicant for a permit subjecu �Ae applicant to a civil penalty o( 3 4 212 0 i 0�(� Number P Y YP
not more �han fiw hundred dollars (5500)•
❑ I. u owner of tlie proPertY• or my employces with wages u the'v sole compansadon.
wiU do the work. rnd the stcucw�e is not intended or ofteced for sale (Sec• 7044• Husi^ess Required Inspections
and Pro[essions Code: The Conuacwr's License Law docs noi ePP�Y 1O �°N'ner of
property who builds a improves thercon, and who das such work himselt or thmugh his
own emptayces. Prmided that such improvemenu sre not in�ended or olkred Cor sale. lf.
hawever. the building or improvement ia sold within one year o[ wmpletion. �he owner-
builder will htve the ba*den oC proving tiiat he did not build or improvc Cor purpose of
sak.).
0 I. u awnec of the proporty. sm enclusiveiy contracting wiih licensed rnnusewrs W
consuuct the Project (Sec. 7044. Businas and Pro�essi �ild �im� ves U�enonsmd .
cenae Law does not apply w m ownar of propeny �n ���ntcacror's
who conuac�s tor suc6 pmjects wiUi a conuactar(s) licensed W
L.i�ense Law. , g g� p C for �hia rcsson
am uempt undu Sec.
_ ..ner
Date
WORKER'S COMPENSATION DECLARA'f[ON
I hercby adi�m under penalty of perjury one o( the [ollowing declarations:
I Asve and wilt mainwin a Certificate of Consent lo xlf-insure (or Workcr's Compen-
satian, u providcd far by Section 3700 ot �he Labur Code. for ihe performancc ot �hc
work for which �his pertnit is iuued•
❑ I have and will maintain Warker's Compensation Insurma, as required by Sec�ion .
3700 0[ the Labor Code. Cw the pedormance af the wort for which �his permit is issued.
My Worke�s Compensation Insmance cacricr a�d Policy number am:
C �� Policy No.:
CERTIFICA7'E OF EXEMPI70N FROM WORKERS' •
COMPENSATION INSURANCfi
(This section necd not bc completed if �e pemut ts (or onc hund�ed dollua (S I00) •
or Icss.)
1 cenify ihut in t6c performance d' thc work fw which �his permh is issucd• � sha�� not
employ any persan in any mmn�r�so u wyecome uhiec� w U+e �Yorlcers� CompensaGan
Laws of Califomia. Duc � �� �� ��
ADP�� �°/ IndT I�:;
N�17CE TO APPLICAM: If, aftcr making �his CcmCcate of Excmpuon, you should
baome subjcct tn lhc Workcr's Compensation ptovisions of thc Lal+or Codc, you muu
�;� (orthwilh comply with such provisions or this permit shall6c dccmcd mrokcd.
Z � CONSTRUCi70N LENDING AGENCY .
F r-� 1 hc�chy alTirm Uut thcR is s constcueuon knding agcncy for thc performancc o�
p(, � ihc wurk for which ihis pem�ii is issued (Scc. 3097, Civ. CJ
W Q Lendcr's Nunc
L� Lcnder's Addtcss
V 0 1 cerufY ih°t I have read tlus appl�cauon snd sia�c �hat thc ahove infortnaliun is
w F cortcct. I agra to comply wiih all riiy and counry oniinances and sute Isws relating to
building consuuction, and heieby autharim rcprescniativcs of this city w cnicr upon ihc
� W atwvamcndoned property for inspeciion purposes.
a (Wc) a�ee to save. indemnify and kecp harmless the Ci�y af Cupertino against
�� liabiliva, judgmcnts, cos�t and expenses which may in any way ucrue against seid ChY ,
() z in conuquence oC the granting ot ihis permi�. Date ',,.�
� APPLICANT UND ST S ILL COMPLY WITH ALL NON-POINT Issued hy:
SO�EG �
��' � � � Re-rooi s
Signazurc of Appl�anUComncwr � T of Roof
HAZARDOUS MATERIALS DISCLOSURE YP
�p ihe applicant or futurc building acupant storc or handlc ha•rardous ma�crial
cfincd by lhe Cupenino Municipal Code. Chaptcr 9.12, md the Heal�h and Safety
.� Scction 25532(a)? � All roo .'s shall be inspected prior to any roofing material being installed.
� ° If a roof is installed without first obtaining an inspection, I agree to remove
Will thc a�licant or Cuwrc building accupant usc cquipmcnt or dcviccs which
emil haiacdous air contaminant5 u defined by 1he Bay Area Air Qus�iry Managemen� all new materials for inspeetion.
a�;���
� y �Nu
I havc rcad �he ha�udous ma�crials rcquiremcn�s undcr C►upmr 6.95 of ihc Glifor-
nia HcalUt & Safcty Codc. Scciions 25 , 25533 uu125534.1 undcrsmnd that if ihc 6uilding
does not curtcnAy a t is respo�sibilily io noufy �hc occupant M Nc Date
� � N , � o� „� ar a c�r�a� or a���r. SignatL re of Appl icant
�� 6" � All roof coverings to be Class "B" or better
Owner or au�horizcd agcn� ���