07110005 CITY OF CUPERTINO ����������*�������
BUILDING DIVISION PERMIT ;. ;::. :
. :::.:..::. ::::<::,: .. .. . ::::...... ..: ,.
PERMIT NO.
eu����vc�A�r�R BA��RT AVE WINDOW I3ROKER - THE 0 7110 0 0 5 .
ti y U
, pERM1T L55UE DATE
NNER NnME: � 11 / 01 / 2 0 0 7
NANCY CHAO 23312 C�1BOT BLVD
SANTTARY NO. CONTROL NO.
PHONE: ��j1O� 2��5-56�10
BUII.DING PERMIT INFO
ARCHI'I'ECC/ENGINEER: BLDG ELECT PLUMB M6CH
� � � �
u p � LICENSED CONIRAC7bR'S DECLARAT[ON JOU DeSCi1�7U0i1
;� � I hcrcby aftirm �hat I am licenscd under provisions oC Chaptcr 9(rnmmencing
�� wiih Sccdon 70ou) of Division 3 of ihc Busincst and Protcssions Codc, and my licensc is RE P LAC E 5 W I NDOW S � 1. S L I D I NG DOO R
�� y in full force and cftx� � �' 3� ���
� v� z Licensc Class �- ` Contraetor
= E ,,, p Dalc
� ARCHITECI'S DECLARATION
e -� I undcrstand my plans ahall be uscd as public records
jyU
L p f �"'„ Liccnscd Pmfcssional
OWNHR-BUILDER DECLARATION
,'� e� I hcrcby alTirtn U�at 1 am excmpt Gum ihc Con�raaor's Liccnsc Law for Uu
p O following rcason. (Scction 7(Y31.5, Busincss and Profcssians Codc. Any cily ar county
� m Qi which rcquircs a permit to cnnswc4 sl�. �{��. �malish. or mpair any swcwrc
'� " y prior ui i�s issuancc, also ccyuircs the applicant for such pertnit to �Ic a signcd smtemeni S Ft. Floor Area Valuation
-�<�� he is liccnscd pursuant to thc provisions o[ thc Conuactor's Licensc Law (Chaptcr 9 $ 6 7 9 0
Y I = -� �(commcncing wi�h Scction 7000) of Division 3 of die Busincss and Profcssions Codc) or
y�$ that he is e:empt thercfrom md the basit [or tl�e al�cgcd ezempdon. Any violation of � Number Occupancy Type
Section 7031.5 by a�ry applicant for a permlt subjecu the aPPficant to a civil pcnalty of 3 7 5 3 3 0 0 6 .` U'll '
not mote Ihan fiw hundred dollars (5500�
❑ I. u owner of the propertY. or my a°ployces with wages u thc'v solc compensadon,
will do the work. and the st�ucwre is not inteneed or oftemd tor sa� (5«. �oeti. Bus�ness Required Inspections
and Professions Code: The Conuutor's License Law do�s not apply to an owner of
propeny who builds or improves thercon, and who does such work himself or Uvough his
own employces. pmvidcd that such improvemen�s ue not in�ended or oReced (or sale. I[,
hawever. �he building or improvement is sold wichin one yesr ot comple�ion, the owner-
builder will have the burden of proving that he did not build or improve tor purpose af
mk.).
❑ I, ss owner of the propeny. am aeclusively conuacting wilh licensed rnnuutors W
rnnstruct Uie pmject (Sec. 7044. Business and Pro[essions Code:) The Couutractnr's ►.i-
cense Caw docs aot apply io an owner of propeny who builds or improves �hereon, md ,
who contracts Cor such projecls with a conuactor(s) licensed pursuant w tbe Contracror's
License Law.
' I am ezempt under Sec. . B dc P C for this mason ,
.wner Dale
WORKER'S COMPENSATION DECLARATION
I hereby affirm under penalty of perjury one of the following declarations:
❑ I hsve and will mainuin a Cenificam of Consent lo self-inaure for Workcrs Compen-
sation, as providcd for by Section 3700 of the Labor Code. for the perfarmance of thc
work for which �his pertnit is issued-
I havc and will maimain Workers Compensation Insurancc, as required by Scction
7 oC the Labor Code, for ihe performance o[ the worlc for which �his pem�il is issued. .
My Workers Compensation Insurance carticr and Poliry numbcr a�e:
Cartier.�F'�//]`°Y�4 Zi(�� �Qa'1-1,C�iryNo.:�...
CERI7FlCATE OF EXEMPTION FROM WORKERS' .
COMPENSATION INSURANCE
(ihis sectian need not bc complctcd if the pecmit is for onc hundred dollars (5100) ,
or less.)
I aniCy ihut in thc performancc of thc work for which Ihis permit is issucd, l shall not
employ any person in any manner so u w becomc subjcct a the Workcn' Compensauan
Laws of Caiifomia. Datc
Applicant
NOTICE 7'O APPLICAM: If, attcr making Wis Ccrtificate of Exemption, you shoulJ
bccome subjcct to �hc Workcr's Compcnsetion provisions of �c Labor Codc, you muu
, ,'� fonhwi� comply wilh such provisions or this peGmit shall be dcemcd revakcd.
Z � CONSfRUCI70N LENDING AGENCY
E. ►�-� I hereby affirm that ihcre ia a consuuction lending agcncy 1'or the perfarmana o(
Q,! � tho work fnr which ihis pemiit is iuued (Scc. 3097. Civ. C.) .
W Q I,endcr's Namc
] z Lcnders Address
V � I cenify that ] have rcad Utis appiicuion and siatc �at thc above informadon is
w � cortcct 1 agrce �o comply with all city and counry ordinances and sia�e laws relating to
� U building conswcdon, and hcreby authorise representativcs of ihis city to cnter upon tAc
� W atrovc-mcntioned propeny for inspccuon puqwses
a (We) agrce to seve, indcmnify and kecp harmless �he City o[ Cupenino against
�� liabilitiu, judgmcn�s, costs and e sca which may in any way accruc against said City
V z in conxquencc o[ tAc gran6 �n�s ���. Date
►�" APPLIC UNDER S AND WILL COMPLY WITH ALL NON-POINT Issued �y :
SOUR •
- Re-roof ;
urc of uanUConuazwr � T of Roof
HAZARDOUS MATERIALS D[SCLOSURE YPe
Will thc applicant or future building occupant storc or hsndlc ha•rallous matcrial
;afincd by the Cupenino Municipal Codc. Ct�ap�cr 9.12, snd thc Hcalih and Safcty
,�,�. Scction 25532(a)? All roots shall be inspected prior to any roofing material being installed.
�y� No •
�,C If a roo; is installed without first obtaining an inspection, agree to remove
Will the applicant or future building occupant use eyuipment o�tlevices which all new materials for inspection.
cmit ha air contaminanu as cicfincd by thc Bay Arca Air Qualit Mana cmcn�
District?
�ya Nu
I havc rcad ihe hs�ard ��crials rcquitcmcn�s undcr Chap�cr 6.95 0( � Cali(or-
nis Hcalih & Safery Codc, 505, 25533 anci 25534.1 undcrstand thauf ihc b���ding
docs not curren�ly havc a 111at it is my rcsponsibility m noufy thc occupsnt of thc Date
myuire n�c me� �;o� a��u ore c«wx� ora���r. Signatu -e of Applicant
�l l�� All roof coverings to be Class "B" or better
cr or auth d agcni ���