07100219 CITY OF CUPERTINO ������ :
BUILDING DIVISION PERMIT , :_ ;:: ::
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pERMIT NO.
BUILDING ADDRESS: .
20306 PINNTAGE PARKWAY M.L.NIELSEN CONSTRUCTION 07100219
pERM1T LSSUE DATE
., ANER'S NAME: .
CAROLINE BANGHAM 4608 ENI'ERPRISE CMN 11/15/2007
SANITARY NO. CONTROL NO.
P"o"E: ( 510 ) 657-6764
BUILDING PERMIT INFO
ARCHITECT/ENGINEER: BLDG ELECi PLUMB MECH
0 0 0 0
� a o LICENSED CON7'RAC1'OR oeci.nRnnox Job Description
V ! hcrcby �cm �hat I am liccnsed undcr provisions of Chaptcr 9(commencing
� z � witA Scction 7000) of Division 3 of Ihc Busincst and Pro[cssions Code and my �icense is RE PA I R 0 F DAMI�GED F L00 R JO I S T S ( 2 ND F LR )
�� y in full force a C � �� � 0
► � Z Licenac lata �_
.. �� � .- Conuactar M . L . N � �.l :� o�
: � � A CHITECI'S DECLARATION ty� ( .
� < 1 undcrstanJ my plans shall be used u public rccorda
�yU
; u. y Liccnsed Pn�fcssional
� y � OWNER-BUILDER DECLARATION
� q I l�ercby alYrm �hal 1 am excmpt Crt�m �hc Conuactors Liccnse Law for thc
p O Collowing resson. (Scction 7U3I.5, Busincss and Pro(c.csions Co�c: Any city or coun�y
K,°, � which mquiecs a pennit to conswct, alter. improve. demalich. or iepair any svucwrc
'� ' y prior u� i�s issuance, also requircs thc applicant (or such permit to filc a signed s�a�emcnt Ft. Floor Area Valuation
� Z< tha� he is licenscd pursuant to Ihe pmvisions ot the Conuactoi s licensc law (Chapter 9 S9 • $ 5 0 0 0
z t�- $(commcncing wi�h Scction 7000) of Division 3 of dic Busineu and Profcssians Codc) or
y�., �hat he is exempt the�efrom and the basit for �Irc allegcd exemption. Any viotauon ot Number Occupancy Type
Section 7031.5 by arry applicant for a permit subjecu ihe applicant to a civil penalty of 3 6 9 4 7 0 7 4��
not mo�e than five hundred dollars (5500)•
� 1. u owner ot tt�e property. or my employces with wages u their solc compeosadon,
wiu do che work e�d ihe suuctum is not intended or ot[e�ed tor ss�c (sa. 7oea. Bus�ness Required Inspections
and Professiona Code: The Conuuwrs Liw�se Law dors not apply �o an owner of
Pro �y �y� y����s oc �mproves thereon, and wM daes such wodc himselt ar tluough his
own employces, provided that such improvements ue not in�ended w o[feced Cor sale.l[.
however. the building ot impmvemenl is soid within one year oC compledan. the owner-
builder wiU hare the burden oC proving Uiat he did not buiid or improvc far purpose ot
sale.).
Q 1. u awner oC the properry. am aectusively convuting wi�h Iicensed rnnvactors to
consuvct the pmjoct (Sec. 7044. Businm and Professiora Code:) The Contrxwr's Li-
cense Law does not apply in an awnm of PropenY who builds or impmves themon, and .
who convscu for such projecis wi�h a con�cactor(s) licensed pursuant to ihe Convacar's
. '^ense Iaw.
am exempt under Sec. , B& P C for this rcason
Uwnu Due
WORKER'S COMPENSATION DECLARATION
I hercby aCfirm under penalty ot perjury one o[ �he following declaruions:
❑ I hsve and will maintain a CeniGcam of Conunt w ulf-insurc tor Workers Compen-
sation, u provided (or by Section 3700 of �he labor Code, for the performa�rce oC the
woric Cor which �his prrtnit is issucd.
havc and will mainuin Workcts Compensadan Insurana. as �cquired by Scction
7 0( the LaEor Codc. Cor thc pedortnanu o( ihe work for which �his peemit is istued. �
My Wor�s C lnsutanm curicr a�d PoGc7' number me:
CartiCr DAt!+ JeA ��l' ��.d�13�p xo.: W� A3 4 G 3�
CER17F[CrCi'H �F EXEMPfION FROM WORKERS' .
COMPENSATION INSURANCE
(This scction necd not bc completcd if the permit is far anc hundred dollara (S10(1) ,
or Icss.)
1 cenify Ihat in Ihc performancc of tdc work fw which this permit is istued, l shall not
employ any person in any man�r so as m bccomc subject to the Workcrs' Compenutlon ,._
Laws of Califomia Datc
Appiicant
NOTICE TO APPLICANI': If, af�cr making this CertiCcate of ExempGon, you shauld
bccome subject w thc Woricer's Compcnsation provisions a( Nc Lsbor Codc, yau must
�',� forthwiU� comply with such provisions or this permit shatl6c dccmcd ccvotcd.
� O CONSTRUCCION LENDING AGENCY
[..r .• I hcmby aRrm �hat thcm ia a consuuction knding agcncy for ihc perfortnance o(
a✓ the wark Cot which �his permit is iuued (Scc. 3097. Civ. CJ .
W Q Lendcr's Namc
�+ L.cnde�s Address
V � I cenify Ihat I have tead �his spplication and sutc Ihat �hc above inlortnatiun is
w � cortect 1 asree w comply wiih all city md counry ordinances and sute Iaws reladng w
� U buildins consuuction, and heieby suthori�s ccpresen�aUvcs of Uiis cily to enter upon ihc
� W alwve-mcntioncd propeny for inspection purposes
a (Wc) agiee to save, indemnify aod keep harm�ess Ihe Ciry of Cupertino against �/ ��
liabiliva,judgmcnls, cosls and expenses which msy in any way ucruc against said City � /
V z in consequcnce oC thc ��S P�fmi Date
r-i AND ND WILL COMP WITH ALL NON-PO1NT Issued by :
U
� I - (o- a`� Re-roof:; �''" �•-'�
s�gn,wrc ppuanuca�troc�o� �'� TYPe of Roof
HAZARDOUS MA?ERIAlS DISCLOSURE �
Will Ure applicant w futwc building occupant storc or handlc ha•rardous matcrial
:fincd by Ihe Cupertino Municipal Codc. Chaptcr 9.12, and �he Hcalih and Safcty
,.:,� Scction 25532(a)? All roof � shall be inspected prior to any roofing material being installed.
� �`° If a rooi is installed without first obtaining an inspection, I agree to remove
Will the applicant or future building accupant usc equipmen� o ydcvices which all new materials for inspeetion.
emit haiardous air contaminants u dcfincd by the Bay Arca Air Qualit Mana cment
Disuict?
� ya �flu
1 havc rcad �he hvardau matcrials requircmcn�s undcr Chapicr 6.95 of Ihc Califorv
nia Hcalth & Satcty Codc, Sccuons 25505.25533 anJ 25534.1 d U�at iCthc building
� havc a at it is my responsibiliry n ufy ihe occupant n( �he Date
� tpn r issu oraCcnir fo��p�rcy�_O� Signatu��eofApplicant
� All roof coverings to be Class "B" or better
Owncr or autho .c agcnt D,�