07110173 CITY OF CUPERTINO ° `
PERNIIT , �������TR.��Q������
BUILDING DIVISION '
;: ;. >: ..::. :. .. .
;: ... _. _. ..
BUILD(NG ADDRESS: PERMIT NO.
19710 DRAKE DR ANDERSC�N-NISWANDER 07110173 .
OWNER'S NAME: PERMIT LSSUE DATE
MACIAS ROBERT M AND ELVIA M 3620 HF.VEN AVE � 11/30/2007
)tYE� SANTTARY NO. CONIROL NO.
(650)3E9-9443
ARCHITECT/ENGINEER: BUiLDINC PERMTI' INFO
BLDG ELECI' PLUMB MECH
� O p LiCENSED COMRACTOfl'S DECLARATION O O 0 �
� I hcrcby afGrm thal 1 am liccnscd undcr provisions of Chap�cr 9(commencins Job Description
� z� ai � h S c cGo n 7 0 0 0) o f D ivisi on 3 of thc Busincss and Protcssions Codc, and m y liccnse is V O L N T A F . Y P R E S C R I P T V S E I S M I C U P G R A D E
�� a in full force and c P
� � ,Z� Licensc Class �- " � � Lic. 8 �;L.� �` � �
_ �, � Da�c 11 — e=�"'( Conlnctar
ARCHITECI'S DECLARA
�� U I undcrstand my plans shall bc used u pu6iic rccords
d
i O y Gccnsed Rufcssional
n y � OWNER-HU(LDER DECI.ARATION
�`� I hcrcby allirm that I am excmpi Gum ihc Contractor's Licensc Law for U�c ,
y p o foliowing icazon. (Scction 7031.5, Busincss and Profcssions Caic: Any city or county
y$ Pi which rcquires a pc�mi� to consuuc� altcr. im�xove. demalish, qr �epuir any svucmrc
_ Z} prior w i�s issuancc, alsu rcquircs thc applicant for such permit io filc a signcd s�ammcnt
�_ � tha� he is lice� d pursuant to ihc provisions oC ihc Conuactur's Liccnsc Caw (Chaptcr 9 Sq. Ft. Floor Area $ 610 0 Valuation
Y F (commcncin wi�h Scction 7000 of Division 3 of ihc Business and Profcssions Codc) or
y�� thal Ae is exempl themfrom and the besia for �he allcgcd exemption. Any violadan of
Secuon 7031.3 by uty applicant (or a peimit subjecu the applicant w a civil penalty of Number Occupancy Type
rwt more than five hundrod dollars (5500). 316 3 2 0� 0.`
❑ I, aa owncr o[ t(ie prope:ty. or my employca with wages u the'v solc compensaUon,
wilt do �he worlc, and the stnuwre is not intended or oftered for sale (Sec. 7044, Businrsa Re uired Ins eetions
and Ptokssions Code: The ConUactor's License law doa not apply W an owner of �] p
pmperty who builds a improves UKrcon, and who does such work himsel[ or through hu
own employccs, provided that such improvemenLS are not inm+ided or oRered for sala If,
however, ihe building or impiovement ia sold within one yeu o[ compleGon, ihe owner-
builder will have the burden of prnving �at he did no� build or improve tor pu�pose of
sakJ.
❑ 1. as awner o[ the propeny. am enclusively contruting wi�h Iicensed conuactors w
wnstma the pcnject (Sec. 7044. Business and Profcssions Cade:) The Coavuwr's Li-
ccnse Law docs not apply w an owner of propeny who builds or improves the�eon, md .
who conuacls for such p�ojects with a conuactar(s) licenxd pursusnt w �he Convactors
License Law.
❑ I am aempt under Sec. , B& P C for ihis reaaon
Owner Date
WORKER'S COMPENSAT[ON DECLARATION
1 Aemby �rtn under penalty of perjury one o[ �he folbwing declantions:
( have and will mainuin s Cenificate of Conaent to xlf-insure [or Workefs Compen-
satian, at providcd for by Section 3700 of the Labor Code, for �he perfarmanx o[ the
work for which Ihis permit is issucd.
❑ I havc and will maintain Workers Compensation Insurana, as �cquired 6y Scction
3700 of thc Labor Codc. Cw thc pcdormmce of �he wak fw which �his pecmit is istued. '
My Workers Compensation Luunnce carrier and Policy number aze:
Cartier: ��'r�e r"'��'� Poliey Na.: 7L4- C:C�D ?S? �i
CER7'IFlCATE OF EXEMP170N FROM WORKEItS'
COMPENSATIONINSURANCfi .
(This section need not be completed if the permit is for onc hundrcA dotlsca (S 100)
or Icss.) .
i cenify ihat in tdc performancc of the work for which ihis pertnit is iuucd, 1 shall not
eenploy any peeson in any manncr so u m beeomc subject to the Worke�s' Compensalion
Laws o( Califomia. Dam
Applicant
NOTICE TO APPL[CANT: If, aftcr making �his Certifica�c o( Faccmption, you ahaulJ
becane subjcct a �hc Worker's Compcnsatian provisions of ihc Labor Codc, yau muu
. ,`� foMwit6 comply with such provisians or this pewnit shall bc dcemcd revaked.
z O CONSTRUC170N LENDING AGENCY
.� N
(-r ►-� I hc�c6y alTirm Uut �hcre is a consuucunn Icnding agcncy [or �hc perfortnancc uf
Qi � ihe work for which this pertnit is issued (Scc. 3097, Civ. C.) '
W� Q Lendefs Namc ,
� z C.ender's Address
V � 1 certifY Ihu J have rcad ihis application and statc ihu thc above informstlun is
w�" cortcc� I ag�ce w comply wiih �II ciry and county ordinances and suk laws relating w
� U building consuuction, and hereby amhoria represenutives of this ci�y to entcr upnn ihc
� w above-mcntioned propcny !or inspcciion purposex
a (Wc) ag�ce to save, indcmnify snd koep harmless the Ciry af Cupcnino against
�� liabilitla, judgmcnts, cosls and expenscs which may in any way uccue againsl said City
V,'� in cansequeMe of ihc granting aC Ihis permit.
�"� APPLICANT UNDERSTANDS AND W1LL COMPLY WITH ALL NON-PO1N7 Issued by Date �i— 3��
S E REGULA ONS.
��- 3 0- c^:-'� Re-roofs �..__..
Signaturo of Applianl/Contracwr � Da�
HAZARDOUS MATERIALS DlSCLOSURE Type of R oof
Will the applicant or futurc building occupant uorc or hendle ha•raMous ma�crial
u defincd by the Cupenino Municipal Codc, CF�ap�r 9.12, and thc Hcalth and Safety
c«k Section 25532(a)? All roofs �hall be inspected prior to any roofing material being installed.
❑ Y� �U�/
Will �hc applicant or fuwec building occupant usc equipmcnt or Jcvices which If a roof i; installed without first obtaining an inspection, I agree to remove
t harardous air con�aminanLS az dcfincd c Bay Area Air Quslily Managcmcnl all new m aterials for inspection.
_,s�;��� �
❑ vcs
1 havc rca�i ihe ha�ardous mamrials requiremcnu undcr Chap�cr 6.95 of dic Califor-
nia Hcal� & Safcry Cade. Smiong 25505, 25533 anJ 25534.1 un�rsmnd that iCthc building
does not curtcn�ly havc a icnant, �Aat it ia my msponsilriliry w notiCy the accupant of the
� �� Ww�e m� x�� �;o w��� ar, c�r� oro���r. Signature of Applicant Date
'`^�` � �(''`'� ��� All roof coverings to be Class "B" or better
O�u tt i or autharixed agcm Datc '