07110129 CITY OF CUPERTINO ` '
BUILDING DIVISION PERMIT �������� ���������''
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BUiLDING ADDRESS: PERMIT NO.
10201 HILLCREST RD LIPP ST VEN C& HEIDI 07110129 .
OW NER'S NAME: �� �� D ' 4 �
LIPP STEVEN C& HEIDI 10201 HCLLCREST RD � 11/21/2007
PHONE: SAMTARY NO. CONTROL N0.
:CHI'IECI'/EIVGINEER: BUILDING PERMCf 1NF0
HLDC ELECT PLUMB MECH
0 0 0 0
u p p LICENSED CON'fRACCOR'S DECLARATION JOU DeSCiIpClOi1
i� V I hcrcby affirm that I am IiccnsM under provisions of Chaptcr 9(commcncing
�� � wi�h SccGon 7000) of Division 3 of thc Busincsr and Profcssions Cadc, and my liccnse is [n1I NDOW : ZE P LAC: MENT L I KE F O R L I KE
y in full fo�ce and eftect
� ? Licenac Class ��• �
' F,q Da�c Conuacwr
'4 ARCHITECTS DECLARATION
3 I understanJ my plans shall be u+cd as public rccarda
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d
U
� O y Licensed Pcufcssional
n y � OWNER-BU(LDER DECLARATION
1 hcrcby a�rtn �at 1 am cxcmpt Crom �he Coniractors Liccnsc Law for thc
� p O following icuon. (Scction 7031.5, Busincss and Profcssiuns CoJc: Any ciry or rnunry
K°, Pi which rcquima a pertnit a cnnswct, slmr, impmvc, dcmolish, or repair my suucture
y Z � prior w i1s issuance, alsu rcquims Uic applicant (or such pertnit �o filc a signcd s�a�cmcn� �,
<�az �� licenscd pursuant to thc p�ovisions o[ thc ConuacWr's Liccnse Law (Chaptcr 9 .>q. Ft. Floor Area Valuation
y t = - $(commcncing wiih SecUon 7000) o( Division 3 of �hc Busincss and Professiona Codc) or � 1 � � � �
y �.. �hat he is exempt thercfrom snd We basis (ar the alleged exempdon. My violauon of
Section 7031.3 by a�ry applicant for a permit subjecu the applicant to a civil pcnalty of Number Occupancy Type
not more than fiw Aundred dollars (5500). 3 2 616 0 6�`°���
❑[. u owner of the property. or my employcea with wages u their aolc compensadon,
will do t6e wortc, and �he stcucwie is noi intended or ot[ered for sale (Sec. 7044, Business Re uired Ins eed ons
and Professions Code: The Convxtors Lianse Law does not apply w an owner ot q P
prapeny wha builds or improves �hercon, and wha daes such woric himaelf ar thmugh his
own empioyces, provided �hat such improvements are not intended or oRered for sala 1[,
however, �he building or improvement is sold within one year oC rnmpletion, the owner-
builder wiR have �he burden af proving that he did not build or impcovc for purpoae ot
saleJ.
I�]�.+ ownec of the property, am e:clusively conuacting wi�h Gcenaed rnnvacwrs w
dfisuuct the pmject (Sec. 7044. Businas and Professions Cade:) The ConVactnr's Li-
cense [aw does not appiy to an ownu of property who builds or impraves themon, and ,
who convacis tor such projects with a coniractor(s) Iicensed pursuant W �he ConvacWrs
License Law.
❑ t am ezempt undu Sec. , B& P C for �s re n
�� � �1n _ D.� 2 G
�O KF.I�S SATION DECLARA170N
1 hereby affitm under penalty of pe�jury ane o[ ihe following declaratians:
❑! hsae and will mainuin a Cenifiate of Consen� lo ulf-insum for Workcr's Compen-
don, as provided for by Secuon 3700 af the (abor Code, for the performancc o[ the
rk for which Ihis permit is issued.
❑ I have and wiU maintain Workcts Compensation Insurana, u tcquired 6y Scction
3700 of �he Labor Code, Cor the peRartnance of ihe wocic for which �his permit is issued.
My Worke�s Compensauon lnsunnce carticr and Policy numbcr are:
Carrier: Poliry No.:
CERTIFiCATE OF EXEMP'1'ION FROM WORKEttS'
COMPENSA'[70N INSURANCE •
(ihis section necd not be canplctcd if the permit is for onc hundred dollars (5100)
or Icss.) •
I cenify �ha1 in �hc performancc of Wc work for which Ihis permit is istucd, I shall not
employ any pccson in any manncr so ac m 6ccomo subject to the Workcrs' Compenaadon
Laws of Cali Dalc
Applicanl ��� —�`
NOTICE 7'O A CAM: If, aMr making �his CcniGcatc of F�ccmption, you should
become subject W the Worlcer's Compensation ptovisions of �he LaAor Cod0. you must
� O forthwiUi comply with such provisioas or this pecmit shall be de�med mroked.
z "" CONSTRUCI'ION LENDING AGF.h1CY
(-�i � 1 hcmby aCfirm ilut thcre is a consuuction Icnding agcncy for ihc perCormukc of
R�i � ihe work for which this permit is issucd (Sec. 3097, Civ. CJ
� Q Lendcr's Namc •
� z Lender's Addmss
V 0 ! ceriifY ihat 1 have read ihis application and stam ihal thc a6ove informatiun is
w� cortcct 1 agrce to comply wi�h all city and county orefinances and s�ate iaws relating w
0 U buildin6 consuuction, and hercby authori�t represen�ativcs of this ciry w cnlcr upon tAe
� w alwve-mentioned property for inspenion purposet
Gy (Wc) ag�ce to save, indcmnify and keep harmless �he Ciry of Cupertino against
��, � liabilities, judgmen�s, costs and expenses which may in any way accruc against said City
V z in consequence oC Wc granGng oC this permit. y Date � � 2 J� /
�+ APPWCANT UNDERS'TANDS AND WILL COMPLY WITH ALL NON-POINT Issued b:
SO(1 CE REg GULA7SONS. ��
���C�r� .----� 11 � 2 1 Re-roofs
Sig at of Appiican ntracwr Da(c
HAZARDOUS MA7'ERIALS D[SCI.OSURE Type of Rc �of
�p Ihc applicant w futwc building occupant storc or handlc ha•rardous matcrial
u dcfined by �he Cupenino Municipal Cadc. Chaptcr 9.12, md �hc Hcal�h and Safcry
c� Scction 25532(a)? All roofs shall be inspected prior to any roofing material being installed.
❑ vcs �.No
wli the applicant or future building accupant use cyuipment or dcvices which If a roof is installed without first obtaining an inspection, I agree to remove
emit hazardous air con�aminants u dcfincd by the Bay Area Air Quality Managemcnt all new m� terials for inspection.
���;���
❑ Ycs � Nu
I havc rcaJ the hvardous maicrials requi�emcn�s undcr Chaptcr 6.95 of ihc Califor-
nia FIca11A & Satcty Codc. Sccfions 25505, 25533 and 25534. ( undcrs�v+d Uiat iCthe building
does not curtcntly havc a tenan4 ihat it ia my responsibiliry w noufy U�c cecupant of ihe
rcy ' en Wn;�n m� � m« �;a� w�u� or. c�rua� ar o���y. Signature c �f Applicant Date
�� "�Z� �� All roof coverings to be Class "B" or better
Owner or w�horiaed agen� D�T—