06110069 CITY OF CUPERTINO ' ;
BUILDING DIVISION PERMIT ������� ���������
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BUILDING ADDRESS: % ��`,. PERMIT NO.
•�7� � L TBD TC BE DETERMINED 0 6110 0 6 9 .
9�
PERMIT ISS[IE DATE
� �R'S NAME: ,
� � '' M, � 11/14/2007
SANITARY NO. CONTROL NO.
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BUiLDING PERMITINFO
ARCHI'iECf/ENGINEER:
pG ELE . PLU M
u O p LICENSED CON'fRAC1'OR'S DECLARATION JOb DCSCflpUOO
V� I hereby af(itm that I am licensed undcr provisions o[ Chaptcr 9(commcncing
� x� wiih Sccuon 7000) of Division 3 of ihc Busincss and Protcssions Code, and my license is S FDWL : 3 E 2 7' GARAGE : 4 8 7' C OVERED PORCH : 6 7' PERM I T
�� y in full foice and e(Cec� �� * APPL EX7'ENDED T I LL 11 / 15 / 0 7
� v� Z Licenac Ctus Conlractnr
:�' o°a ARCHI'I'EC1'S DECLARATION 5 6. 3 8 X 4 8 7 = 2 7, 4 5 7. 0 6 3 8. 51 X 6 7 = 2 5 8 0. 17
��� I u�crs�anJ my plans sha116c uud u pubiic �ccorda
� pW, V
� w� y Liccnsed Prufcuional
y � OWNER-BUILDER DECLARATION
' � hcrcby a((irm Ihat I am excmpt from �hc Conuuior's Licenx Law far thc
� p o following rcasan. (Scction 7031.5, Busincu and Profcssians Cafc: Any ci�y or county
y� Pi which requims a pcimit w consuvc� alur. im{xovc, demulish. ar �epuir any stnrcwrc
prior w i�s issuancc, alw rcquircs ihc applican� for such pertnit to file a signcd sta�ement � q , Ft. Floor Area Valuation
— z< that he is liccnsc d pursuan t to t h c p m v i s i o n s o f t h c C o n u a c W r s li c c � s c L a w ( C h a p i c r 9 $ 8 0 7 5 5 6
Y 1�-� �(commcncing wi�h Scction 7000) of Division 3 of Ihc Busincss and Profcssions Cadc) or
y�., that he is exempt �he�etrom md the basis for the allcgcd exemption. Any violation o[
Secdon 7031.5 by arry applicant for a permit subjccu ihe applicant w a civil penaity of �N NlliT1I�r Oeeupancy Type
not more �han fiw hundred dallars (5500)•
❑ I. ss owner o[ tt�e property. or my employca with wages u their sole compensadon.
wiu do we work. and we suuctwe is noe intended or of[e�ed torsa� (s«. �044. Bus�nesa Required Inspections
and Professions Co�: 71�e Conuacwr's License Law does not apply a an owner of
propeny who builds or improves thercon. and wM daes such work himaelf ar thcough hu
own employces, provided �hat such improvemrn�s ue not intended or otie�ed Cor sale. IC.
however, the buildiag or improvanenl'u sold wiihin one year o[ complcGon, the owner-
builder will twve the burdee of proving �Iwt he did irot build or improve for purpose of
salc.
1, u awner of the property. am acclasively conuacting with licensed convaclors to
wnstruct the projea (Sec. 7044. Susiness and Professions Code:)'Ihe Conuacwr's Li-
cense Caw does not apply W an owner of propeny who builds or improves Ihenron, and ,
who convac�a for such pmjeas with a conuxtar(s) licenxd pursuant to �he Contncwr's
Licenae Law.
t am exempt under Sec. , B& P C this rcawn
oer Daie
KER'S PENSATION DECLARATION
I qe y affirm under penalty of perjury one of the followine datarations:
❑ I hsae will maintain a Cenificate of Consent to self-insure for Workcr's Compen-
sation, u rovidcd for by Secdon 3700 of the Labor Code, Car �he pedarmance of thc
woric Cor which Ihis pertnit is issued.
❑ I havc and will maimain Workc�s Compensa�ion Insurance, u�cquired 6y Scction ,
3700 of �hc Labor Codc. Cor thc pedormance of �he work for which �his pecmit is issued.
My Worket's Compenaadon Insunnce carticr and Policy number aze:
Cartier. Policy No.:
CERTIFlCA'fE OF EXEMPITON FROM WORKERS'
COMPENSATION INSURANCE �
(This scctian need not bc compietcd if �6e pecmit is for onc hundred dollars (S 100)
orlcss.)
i cenify thnt in thc performancc of �hc work tor which ihis permi� is issucd. 1 s6il1 not
employ any person in any manncr so ps to become wbject ihe W rkc ' ompensadon
Laws of Califomia Da�c
Applicanl
NOTlCE TO AP ANT. If, a making �his CertiC tc of Excm tion, you should
bccome subj to thc Worlcer's Compensation provisions of the [s6or Codc, you muu
�`� forthwilh co y with wch provisions or this permil shall bc dcemcd revokcd.
� O CONSTRUCCION LENDING AGENCY
E.r �--� t heroby afGrm �hat thcre is a constnxGon Iending agency Cor thc perfortnancc u[ .
�,, ✓ the work for which ihis permit is iuued (Scc. 3097, Civ. C.)
W� Q L.endcr's Namc
L.cnder's Addcess
U 0 ( certify Ihat 1 have rcsd this application and stale iAat lhe above informalion is
w � �orteex, ( agrce w rnmply wiUi all city md county oMinu�ces and sute laws mlaung w
0 U buildins consuucGon, and hereby authorim repcesentatives of �his city w en�er upnn ihe
� W alwvc-mcntioned p�opcny for inspection purpcues
a (Wc) asrce to uve, indcmnify and kecp harmless We City of Cupertino against
� y liabiliva, judgmcn�s, cosLS and enpensu which may in any vray accnu against said City
V z in consequence oC thc granting of this permiG Date
►� APPLICANT UNDERSTAND AND WILL COMPLY WITH LL N N-POINT Issued by:
SOURCER ULATIONS. �, / G
� Re-roofs
s��� or IipnVConuactor °"� Type of R��of
HAZARDOUS MATERIALS DISCLOSURE
Will thc applicant or fu�wc building occupant storc or handlc haiardaus matcrial
�ined by thc Cupenino Municipal Codc. Chapicr 9.12, and the Hcalth and Safcty
�. Scction 25532(a)? All roofs : hall be inspected prior to any roofing material being installed.
� Ycs �o
< If a roof i: installed without first obtaining an inspection, I agree to remove
Will thc applicant or fuwre building occupant usc cquipmcnt or Jeviccs which
emit ha•rardous air con�aminants u dcfincd by the Bay Area Air Quality Managcmcn� all new m, iterials for inspecKion.
Disuict?
❑ Ycs �No
1 havc rcaJ �he hvardous maicrials requiremcnts undcr Chap�cr 6.95 of thc Califor-
nia Hcalih & Safcty Codc, Sccuons 25505, 25533 anc125534.1 undcrsmnd thu iCthe 6uilding
Jocs not curtcnUy havc a tcnan4 � it is my rcsponsibility w norify thc occupant nf �hc
myuucmenls which must be met or W issuancc of a Ccnific or o��,P�r. S ignature �f Applicant Date
� � � All roof coverings to be Class "B" or better
Owncr au ri�cd agcnt Datc