08070185.2
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BUILDING DIVISION PERMIT
AVE I TBD — TO BE DETERMINED
0185
NER'S NAME: PERMIT ISSUE DATE
/ 1 1 08/27/2008
ADD 187SQ BDRM, RMDL 1
1 hereby affirm that I am licarved under provisions of Chapter 9 (commencing
with Section TIXMB of Division JafOe Businm W Prafesdvns Code, and mY liccnm ts
k full (ma end effect
Dusts
Lima. Class Le. Is
Dae Conbractar
ARC all x use DECLARATION
I understand my plans shall he used a public rcmrtla
Licensed Pmkossumal
OWNER -BUILDER DECLARATION
1 bmthy anion Nm I am eormpl from the Contmmor's Licenre Law for the
following reaann. (Section 7031.5. Business and Proksumat Cade: Any city of aunty
which ampoms a Permit to cement slur. improve. darmich, or repair my smxture
prior in its issuance, also requires the applicant for such Permit to file a signed subormt
that he is liccnud pursuant to the provisions of the Contractor's IJanre Law (Chapter 9
(commensing with Section 7000) of Division 3 of We Business and Professions Cade) or
Out he is exempt Nuef ck, and the buss for the alleged mereption. Any violation of
Section 7031.5 by any applicant for a peanit subjects We applicant to a civil Washy of
not more door five hundred dollars n -IM
I,uowmar of tie pmperty,amy wployees with wgcau they sok compeweoe,
will do Ncwork and On structure is not intended or offered foruk (Stec. 70M, Business
cad Prefecam. Cade: Th. Conuazmh Lune Law arca rot apply as an owns of
property who build ori op uvea Nmmn,aro surtoarcs sociawork hircifor thmoghbar
own employees, Provided Nat such improvements art not intended or offered for We If,
however, the building or improvement Is mid within ane Year of mmpktkm, Ne owmar-
Wil0er, will have the burden of proving Wad he did not Wild or improv far purpose of
I. u owner of the Sec.7property. , B ureas and
contracting Code;) The
C ntraaclors m
mesa La
the project (Sec. s an Besides dna ny whoons Cade:) The Cmtramora U.
law seascut apply :an owner of property whobuilds serrnI an des Wemomand
who concocts Ire such projects with a con tracot(s) licensed pursuant m the Canuaclor's
License Law./)
❑Iwn� maar5 .Bk PCfm make ion
mar - DateOR
2"p&
WORKER'S COMPENSATION DECLARATION
1 hereby affirm under penalty, of perjury ane of the following dmalaneons:
Ih.a and will mainwa aCenifiaea(ConsunuomlFinsurtforWorker'sCampcn-
amers. as provided fm by Section 3700 of the, Labe Code. far the performance of th<
work for which this permit is issued.
t] 1 have aid will m mmart Wmkcer Onnpeeation I.a, as required by Section
3700 of t e Labor Cattle. far We perf er arce of the work far which this Permit u bound
My Worker's Compensate.. We. carrier and Policy number tic:
Cartier. Palley No.:
CERTIFICATE OF EXEMPRON FROM WORKERS'
COMPENSATION INSURANCE
(Thfsmctim mated mtbecompleed If We permit is foranchummed MO. (SI00)
an, Ina)
I term!). Out in We part..... of the work for which this Permit u issad, I .shell not
em ploy any person, ymanq[r�¢ c subject to the Workers' Compevake.
Iawr ofC
making this CeAOcae of Exemption, you shook
became subject to Wte Worker's Compcutdon provokes of the LabT Calc, you roup
forthwith comply with such provisions or this permit shall l e doem d revoked.
CONSMUCTION LENDING AGENCY
1 hereby.(Acre Wu them u a crosuumitm leading.jimay fm the ismformuda of
We work for which Oris Permit at heated (Sec. 3097, Civ, C)
Lam e's Name
lender's AM.
1 m tlfy that I have read this applicaian read sue this We above Of ..ties is
cornea 1 agree in comply with all city and county odinut and sate laws relating in
Wilding construction, and hereby audboda meresentanim of tbu city in anter upon tie
shove-mmust mad property for irupenian putpme,
(We) agree to cave, indemnify and kccp haealnar We City of Cupenim against
liabilieu•judi ments.cosu and exPeack, which may in my way amue agaimasaid City
WILL COMPLY WITH ALL NON -POINT I Issued by:
HAZARDOUS MATERIALS DISCLOSURE
Rill dM applicant or forum building aaup cumene or handle haudous material
fired by tie Cupertino Municipal Code. Chapter 9.12. and the Health and Safety
Section 255320)?
❑ Yes .
Will We applicant or future building occupsnt um cquipmant or devices which
haysreous air contaminants u defined by Oe Bay Area Air Quainy Mmagemeni
i.t? /
❑Yca call.
-A950fWe C.lifor.
d WaifOe Wilding
the cemprem of We
Required Inspections
Date (S
Re -roofs
Type of Roof /
All roofs shall be inspected prior to any roofing material being installed.
If a roof is installed without first obtaining an inspection, I agree to remove
all new materials for inspection.
Signature of Applicant
Date
All roof coverings to be Class'W' or better