07040080 CITY OF CUPERTINO ''
BUILDING DIVISION PERNIIT �������� ��������
, , ,;:, . . . ..:: .
BUILDING ADDRESS: PERMIT NO.
21837 TERRACE DR TBD —'I'O BE DETERMINED 07040080 .
lER'S NAME: P �� �� DA �
SANPfARY NO. CONTROL NO.
ARCHITECT/E2VGINEER: BUILDWG PERMff INFO
BLDG ELECT PLUMB MECH
� 0 � 0
u O p UCENSED CONTRACTOR'S DECLARATION JOU DeSCT1jJT10fl
m (►�crcyy aflicm that I am licenacd umlcr provisions of Chap�cr 9(commencing
� z� wi�h SccGon 7000) of Division 3 of ihc Busincss and Protcssions Code, and my licensc is ADD 8 6� MA STER BEDROOM & BATH , BEDROOM
'< a in full Cotce and effect
�� uce�x�ass ��.* REMODEIi: PARTIAL BEDROOM� RELOCATE CLOSET.
+ F„ � Datc ARCHITECI'S DEC
� a< 1 undcrstand my plans shall be uud as public mcords
i
; �. y Liccnsed Ptufcssional
n y � OWNER-BUILDER DECLARATION
I hcrcby atTirtn �at t am excmpl Gum the Canuaaors Licensc Law for �hc
� p O following �cason. (Scction '703I.5, Busincss and ProCcssions Calc: Any ciiy or rnunty
K° � which requi�cs a pertnit to conswc� altcr, impmvc, dcmulish, or repuir any swcw�c
y Z� prior lu iLS issuancc. also tcquires �hc applicant for such permit to file a signcd sta�ment
s
�_ � that hc is ticcnscd pursusnt to thc pmvisions of thc Conuactor's liccnsc [aw (Chaptcr 9 Sq. Ft. Floor Area Va uation
y t— �(commcncing wi�h Scction 7000) of Division 3 of Ihc Busincss and Profcssions Codc) or $19 614 8
y �.. that he ia exempt che�efrom and t6e besis Cor the allcged eumption. Any vioiation of
Sectio� 7031.3 by a�ry applicant for a peimit subjecu the applicant w a civil penalty of Q� Number Oceupaney Type
�� �� �n� r�� e�,a,�a aou� cssom. 3 5 617 0 0: t7 U'
❑ I. as owner o[ tlie propercy. or my emptoycea with wages as their solc compensatlon,
wiLL do tde work. snd ihe stcucw�e ia not intended or atfered for sale (Sa. 7044. Businesa Re uired Ins ections
end Professions Code: The Conuaetor's Licenu Law dotl not spply tn an owner of �I p
property who builda ar improves thereon, and who does such worlc himuit or thtougU hia
own employccs, provided that such improvemen�s ue not imm�ded or oReced Cor sale. If,
hawever, the building or impmvement ia sotd wi�hin one year oC completion, the owner-
buildu will have the burden oC proving lhat he did not build or improvc for purpose o(
sa ).
, u owner of the propeny, am acclwively contncling with 6mnxd rnnvactors w
consm�ct the projm (Sec. 7044. Business aad Professions Code:) The Convacmrs Li-
cense [aw docs not apply to an ow�r of propeny who builds or improves �haean, and ,
who conuacts for such pmjecis wi�h a conlrutar(s) lian:ed pursuant to Ihe Convsctor's
Licenae Law.
: am ex pt unda c. . B& P C for �his rcason
� S Dak � l� ��
WORK O S TION
1 hemby �rm under penalty of perjury [ ihe fallowing declaratians:
❑ I hsve and wiil maintain a CeniGcam of Consent to self-insure fw Worker's Compen-
suion, u providcd for by Sectian 3700 ot the Labor Code, for the performancc of �hc
woric Cor which Wis permit is issued.
❑ I havc and will maimain Workcrs Compensation Insurona, as mquircd by Scction
� 3700 oC Ihe Labar Code. Cw thc performance of �he work for which this pe�mit is issued.
My Worker's Compensa�ion Insutance carticr and Policy number a�c:
Camer. Policy No.:
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE •
(Chis sccGon necd not be completcd i( the permit is for onc hundrcA dollua (S 100)
or Icss.) '
I cenily thnt in �hc performance a! thc work for which �his permit is issced, I shall not
employ any person in any mann o ub'at t th orkers' Canpensadon
Laws of Cslifp�ia. Auc —
Appiicant U�4, � 5l
N077CE TO A� : I, atic mak' ihis Cenil"c �c of E:t ptwn, yoT u should
baome subjctt to U�c Worker's CompcnsaUon provisions o( U�c La6or Codc, you muu
, O forthwi�h comply with such provisions or this permi� shall bc dccmcd revokcd.
z "" CONSTRUCf10N LENDING AGENCY
�— � 1 hc�c6y a�rm Nat then is a conswction Icnding agcncy for ihc per[ortnanw uf
p�„ � Uu work for which ihis permit is issued (Scc. 3097, Civ. CJ
W Q l.endcrs Namc •
� � Lende�s Addtcss
V 0 1 cectify iha� 1 havc resd this application and statc that �hc above in(ormatiun is
w�" cortea I agme w comply with all city and counry ordinances and sute laws rctaung w
0 U building consuuction, and hcrcby authoria cepmseniadvcs of ihis city m cntcr u�n ihc
W alwvc-mcnGoircd propcny (or inspcction purposes
a (Wc) agice to save, indcmaify and kecp harmless �he Ci�y of Cupertino against
�„� y liabiliva, Judgmenu, coats and e�cpcnses which may in any way scenie against said City
V z in conxquence ot ihe granting oC ihis permit. DSLe
�'" APPLICANT UNDERSTANDS AND WILL COMP WITH ALL ON-POINT Issued by;
SOU R G ATI � ' I `� �
� Re-roofs
Signawre of Applicant/Con r � alc
H OUS MA DISCI.OSURE Type of B.00f
wll ihc applicant or futurc building occupant storc or handlc ha•rardous ma�crial
'cfincd by thc Cupertino Municipal Codc. Chaplcr 9.12, snd the Hcalih and Safety
k, s��uo� zssszca�� All roofs shall be inspected prior to any roofing material being installed.
❑ Ycs �o
Will ihc applicant or future building occupant use cyuipmcot or Jeviccs which If a roof i s installed without first obtaining an inspection, I agree to remove
cmit harardous air conisminants u dcfincd hy lhe Bay Area Air Quali�y Managcmcnt all new rr aterials for inspeciion.
Disuict? ..�/
❑Ycs �VO
� _ r
I havc rca�i the hvardous maierisls rcquiremcnts undcr Chap�cr 6.95 of thc Califor- ') f� �_ /
nia Flcalth & SafctyCadc, Sectians 25505, 25533 and 25534.1 undcrstand Uia� if Uu building J � �
does not curten�y have a icnan4 iha� it is my responsibiliry noufy ihe occupant of ihe
� �� n ���;o� ��orec aro�� . Signature ofApplicant � Date
r t � f `� � All roof coverings Class "B" or better
Owner or authori�ed agcnl D�