05040017CITY OF CUPERTINO
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BUILDING DIVISION PERMIT�NRACORANFA%tON
.
BUILD INC, ADDRESS:
CLEAR CHOICE
PEKMITND.05040017
OWNER'S NAME:
PERMIT ISSUE DATE
EJE
SANITARY 0 OL NO.
ARCHMIZ71FNGINEER:
BUILDING PERMrr INFO
BLDG EIER PLUMB MECH
I� 0
LICENSED
Job Des
thamRdunderSDECLARATION
I hcmby .(firm Nat I w IkeescO under pmvialom of Chapter 9 (commencing
RNALEr
with Soudan 7") .f Division 3 ofine Businm aid Profeuimu Code. and my license h
full
e4se&p3
BATHROOM REMODEL
LiClan
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Dmnse
G Catsaaar K•OA•R Ol
ARCHITECTS DECLARATION
I undersand my ptaa Nall W used As public memda
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aj
Licensed Professional®�
OWNER -BUILDER DECLARATION
ContoON
I hereby .(firm the 11. exempt from the Conu.etCo License law far the
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following moon. (Sudan EO altar. and r ealnm Cade: MY city m county
mam
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which myuircs. permit m construct. el�n'vnpmve, dcmnlinh, or repair any aratam
sir t. Improve.
prior in its Women. aim requires the Applicant for such permit to rile a signed comment
Sq. Ft. Floor Area
hon
that he is licensed pursuant m the provislmu of me Comuacors License Law (Chapter 9
that
(commencing with Section 7000) of Divisian 3 at the Business and Profession Code) or
that he 6 exempt demfrom and me bests for ON alleged erempdoa. My umbban of
3 M1513tilltbe1`0 0
Occupancy Type
Sada 7031.5 by arty applicant for a permit objects de applicant o. civil penalty of
N, mom dan five hundred dollars (M),
,
❑ I, as owner of Ne Property, or my employeas with wages u dteb role compew0a,
e
Required Inspections
will do me work and the swcture i ... t Mounded or offered tarsals (SAM. 7011. Business
o t apply a an owner of
s Lices Law datro
and Professions Code: The Cooum:tOrm
q P
pmpeny w ho builds ser Improveni thereon, andwho does suc h work Mattel f ser through hen
awn employees, provided met ueh Improvements w no lm ended"offered formle. if,
however. the building or improvement is old within one year of completion, the owner.
Wilder will have the burden of proving that he did ant build o Improve fm purpose of
-
ak.).
❑ I, a owner Of Ne Portnoy. am exclusively contracting with Bcerued cenmanmrs An
construct the pmjm (Sec. 7014. Bumnev and Penfeasiav Cade:) The Conuacmrs Lb
cense law does not apply in an owner of property who ddlds or improv memos. and,
who contracts for such projects with aeonu.no(s) licemed pursuant o me Conu.dOrs
License Law.
C lamemmptunder See. ,B&PCfarthismasan
Owner Dam
WORKERS COMPENSATION DECLARATION
1 hereby affirm under peru ty of Perjury ane of de following declwuou:
ro and will maintain a Certificate of Cometh to self-insum far WokehCompen-
n, a provided for by Section 3700 of sen Labor Code. for the performance of the
w��r�k f/or which this persnil is issued.
Igj�f IIin And will maintain Warkerl COmrinNdon IRWMa, Y required by Section
7700 of the labor Code, fm me performance of the work for which this permit is issued.
My Worker's Compensation Insurance earlier and Policy number am:
Cartier. 21110'" pVVkfl Policy N.,; t Vb77'I.9
CERTIFICATE OF EXEMPTION FROM WORKERS'
'
COMPENSATION INSURANCE
(Thitsectia need Out Wcompicud ifda permit Is for an hundred doled(3100)
or Wes)
1 ceni(y that in mo Performance of the work for which this Permit 4 issued, I shall no
employ any person in any manner an As in became object in the Worked Compenadan
IA. of Celifamie. Data
Applicant
NOTICE TO APPLICANT: IL after making this, Certificate of Exemption, you mould
become subject in the Worker's Compensation provisions of me lahm Cade, you mum
forthwith comply with such provisions "Mm permit shall IN de m til or ma d.
CONSTRUCTION LENDING AGENCY
1 harmy.Ifum that Nem Is a comuuminn lending agency for the runfor ssom m'
Me murk for which this permit is issued (See. 3097. Civ, C.)
Lenders Name
Lenders Address
I certify that I have mad this APPliation and sum mat me above Information is
correct. 1 agree in comply with all city and county ordinances and some laws relating to
building construction, and hereby autborim MPmsmWiM of this city to cater upon the
ahove-memiond property for inspection pugmsea
(We) agree An an, indemnify and keep harmless the City of Cupertino against
liabilides, judgments. cam and expenses which may In my my accrue against aid City
in coMeguemn Of the pressing Of this permit
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON -POINT
Issued by: Date
SOURCE REGULATIONS.
Re -roofs
A"� Y S
Signature O! c.nucott Dam
HAZARDOUS MATERIALS DISCLOSURE
Type of Roof
Wlll the applicant or future building occupant since or handle haardaus macrial
As all by the Cupertino Municipal Cade, Chapter 9.12. and the Health and Salary
Cole, Seetia 25532(.)7/
All roofs shall be inspected prior to any roofing material being installed.
❑Yes MI
If a roof is installed without first obtaining an inspection, I agree to remove
Will the applicant or future bullams oavImm see equipment or device. which
lurardaus Aircauminanu As dalmed by tie Bay Am. Air Quality Management
all new materials for inspection.
ict7
❑Yes Nu
1 have mal the Weamasmaminim requirement, under Chapter 6.95 of the Caiifor•
nine Hal"SalelyCodc, Sections 25305.25533 and 25534.1 undcrond that ifthc Wilding
Jas not currently baro a tenant, that It is my mspamibility, to notify the acupmt of the
mqulmments whim moat be met prior to homen, of a CcNnam of Occupancy'
Signature Of Applicant Date
y�
All roof coverings to be Class "B" or better
Owners omrAgco Data
Q
CY OF CUPERTINO
BUILDING DIVISION PER?
BUILDING ADDRESS:
OWNER'S NAME:
ARCHrrECT/ENGINEER:
LICENSED CONTRACTOR'S DECLARATION
I hereby affirm that 1 am licensed under provisions of Chapter 9 (commencing
with Section 7000) of Division 3 of the Businessand Profession.% Code, and my license is
in full force and effect.
License Class A Lic. N
Date — O Contractor o440i.
ARCHITECTS DECLARATION
1 understand my plans shall be used as public records
Licensed Professional
OWNER -BUILDER DECLARATION
I hereby affirm that I am exempt from the Contractor's License Law for the
following mason. (Section 7031.5, Business and Professions Code: Any city or county
which requires a permit to construct, alter, improve, demolish, or repair any structure
prior to its issuance, also requires the applicant for such permit to file a signed statement
that he is licensed pursuant to the provisions of the Contractor's Liccnsc Law (Chapter 9
(commencing with Section 7000) of Division 3 of the Business and Professions Code) or
that he is exempt therefrom and the basis for the alleged exemption. Any violation of
Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of
not more than five hundred dollars (5500).
❑ I, as owner or the property, or my employees with wages as their sole compensation,
will do the work and the structure is not intended or offered for sale (Sec. 7044, Business
and Professions Code: The Contractor's License Law does not apply to an owner of
property who builds or improves thereon, and who does such work himself or through his
own employees, provided that such improvements are not intended or offered for sale. If,
however, the building or improvement is sold within one year of completion, the owncr-
builder will have the burden of proving that he did not build or improve for purpose of
sale.).
❑ 1, as owner of the property, am exclusively contracting with licensed contractors to
construct the project (Sec. 7044, Business and Professions Code:) The Contractor's Li-
ccnse Law does not apply to an owner of property who builds or improves thereon, and
who contracts for such projects with a contractor(s) licensed pursuant to the Contractor's
License Law.
❑ 1 am exempt under Sec. B & P C for this reason
Owner Date
WORKER'S COMPENSATION DECLARATION
I hereby affirm under penalty of perjury one of the following declarations:
❑ 1 have and will maintain a Certificate of Consent to self -insure for Worker's Compen-
sation, as provided for by Section 3700 of the Labor Code, for the performance of the
work for which this permit is issued.
ave and will maintain Worker's Compensation Insurance, as required by Section
3700 of the Labor Code, for the performance of the work for which this permit is issued.
My Worker's Compensation Insurance carrier and Policy number are:
Carrier. W tni"i8 PLPV%Q Policy No.: I (* G77 X4'9
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(This section need not be completed if the permit is for one hundred dollars (S loo)
or less.)
I certify that in the performance of the work for which this permit is issued, I shall not
employ any person in any manner so as to become subject to the Workers' Compensation
Laws of California. Date
Applicant
NOTICE TO APPLICANT: If, after making this Certificate of Exemption, you should
become subject to the Worker's Compensation provisions of the Labor Code, you must
forthwith comply with such provisions or this permit shall be deemed revoked.
CONSTRUCTION LENDING AGENCY
I hereby affirm that there is a construction lending agency for the performance of
the work for which this permit is issued (Sec. 3097, Civ. C.)
Lender's Name
Lender's Address
1 certify that I have read this application and state that the above information is
correct. I agree to comply with all city and county ordinances and state laws relating to
building construction, and hereby authorise representatives of this city to enter upon the
above-mentioned property for inspection purposes
(We) agree to save, indemnify and keep harmless the City of Cupertino against
liabilities, judgments, costs and expenses which may in any way accrue against said City
in consequence of the granting of this permit.
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON -POINT
SOURCE REGULATIONS.
x■.�raKaS76i 7 � �9
Signature of rcanVConhra6ra Date
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future building occupant store or handle hazardous material
as dcfincd by the Cupertino Municipal Code. Chapter 9.12, and the Health and Safety
Code, Section 25532(a)?
❑ Yes Lair o
Will the applicant or future building occupant use equipment or devices which
emit hazardous air contaminants as dcfincd by the Bay Area Air Quality Management
District?
❑Yes Nu
1 have read the hazardous materials requirements under Chapter 6.95 of the Califor-
nia Health & Sarcty Code, Sections 25505.25533 and 25534.1 understand that if the building
docs not currently have a tenant, that it is my responsibility to notify the occupant of the
requirements which must be met prior to issuance of a Certificate of Occupancy.
y►.-6-'ar
n..._.. _ .._...� .,...., hair
CLEAR CHOICE
BATHROOM REMODEL
Sq. Ft.
Issued by:
Re -roofs
Type of Roof
PERMIT NO.
05040017
PERMIT LSSUE DATE
SANITARY i O. ONTROL NO.
BUILDING PERMrf INFO
BLDG ELECT PLUMB MECH
Job Description
Required Inspections
Occupancy Type
Date
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 "B" or better