05090215CITY OF CUPERTINOx,w«a
BUILDING DIVISION PERMIT
CONTRAGTQR4NFORMATI0N,-R
BUILDING ADDRESS:
PERMIT N0. 05090215
10111 SANTA CLARA AV
OWNER'
02/09/2006
SANITARY NO. CONTROL NO.
ARCHITECT/ENGINEER:
BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
LICENSED CONTRACTOR'S DECLARATION
Job Description
1 hereby affirm Nei 1 am licensed under of Chose. 9 (commencing
P
Proomi
with Section 70flt) of Division 3 of she Business and Professiunn Calc. and my license is
Rod
in mu force and effect.
2-STORY SDWL (2128' LIVING)
LiaClass
BASEMENT-1041'/GAP-AGE-420'
Dam om
Conlramor
ARCHITECTS DECLARATION
1 undersand my plans shall be used as public me.,&
Licensed Professional
OWNER-BUILDER DECLARATION
I hereby affirm Nal 1 am exempt from she ConuxctoYs License Law for the
following mason. (Section 703 1.5, Business and Pmfessiom Cote: Any city or euumy
which require a permit m constrocl, alcor, improve, demolish, Or mi, any alrucmre
prior to its issuance, also ¢puha the applicant for such permit to file a signed sutcment
that he is licensed pursuant to the previsions of the Contractor's License Law (chapter 9
Sq. Ft. Floor Area
VaI ti GIB O18
(commencing with Section 71)(1a)) of Division 3 Of the Business and Professions Coifc) or
Out he u eumpl themfmm and OR basis for the alleged eumpdon. Any violation or
Section 7031.5 by airy applicator for a permit subjects the applicant to a civil penalty of
Number
Apj2Occupancy
YP
Type
not more Ruth five hundred dollars (M).
32624025.00
❑I,u Owner ofthe Property,m withwageutheir ante a
isemployees
will do the wads ted the madam u rlo intended m aRc for tam (Sec. 70e4, ,Business
Required Inspections
o Ito dam not apply ro an owner
Rod do weer of
Code: The Ccs
enywhom
propertywhobuildsaiimpravu demon. and who drusThwork u roffmothrsid his
demon. ndw is
own dict such improvements are ne orrrtcrcA for sale If.
divided
however. Ne building or improvement is old within one year of
ver. OR Wilding year 1c
for the owner-
tr,�
improv
builder will have the burden of proving Out k did Out build Or improve for purpose of
sale..
I�[E�jEjt77ttI755y�_y�-ts
RNALED
I. awnef of sue exclusively Professions with Harmed tors m
amec.
y7/�//���ptj}]gA1
Sprepwy,
r 704. B mmatt Li-
ome, not (Sec.?oa4,Businessand Professions,whCode:)The Co
La des
come, Law law tinea not apply loan owner of properts) lire builds or improve Ammon, red,
theme,
who contracts for such withaconeanor(s)liecnud Contrmmr's
�� _
pmlecu pursuant
LKCIIY Ito.
7
a q00]
L 1
❑tom
NDECLARATION
I hereby affiml der penalty of ped one of the following decorations:
M1a.o and will mamuin aCerdGnte of Cansenuo self-insure for Worker'sCompen-
mile.. u provided for by Section 3700 of the Tabor Cade, for OR No.... of use
we& for which this permit is issued.
1 have and will mainum Worker's Compensation Imuran¢, as required by Section
'
3700 of the labor Code. for the pcermort of the wodt for which this Permit is issued.
My Worker's Compatsation Insurance carrier end Pali, number art:
Carrier. Poli, No.:
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(Thu aced. need not beeornplcud if the permit is (soon hundred dollars (Sial)
nr Mss.)
1 ccnify Not in the perfnrmance of thc work f r wM1igh Nis/M���omit is issud,eI shall nm
employ any person in my manner so as c s it WorkeKcminde sa,ims
Laws of California. Date �+
Applicant
NOTICETO APPLICANT: Exemption, you mould
become subject ut the Worker's codon pmvisidsa4f the Labor Code, you most
roMwith comply with suPM1 pore Onsothia prrmil Ibc deemed revoked.
CONSTRUCTION LENDING AGENCY
1 hemby Rimm Nat chert is eonsuuninn lending agency for the performance of
Rue work for which this permit u issued (Sec. 3097, Co. C.)
Tender's Name
Lender's Address
I ccnify, that I have mad Nis application and arm the Jac "W. infomasiun is
corms I agree m comply with all city and county ordinances and state laws relating to
building construction, and hereby authorire mpmsentmives of this city to enter upon the
shove mentioned propcny for inspeNo. purpmeR.
(We) agree to save, indemnify and keep harmless the City of Cupertino against
liabilities. Judgments, costs and expenses which may in any way tame against said City
ins of this D mit.
A consequence of PPLICANT UNDERSTANDS
SOURCE AND WILL COMPLY WITH ALL �NP INT
A�
Issued by: Date
99
Re-roofs
Signuum AP{�so Dale
ry/SARDOUS MA AIS DISCLOSURE
Type of Roof
Will the fiend; for futurebuildio acopntuoembandleharvdousmaurial
ss elcimed by the Cupertino Municipal Code. Chapter 9.12, and the Health and Safety
Code. Secure25532(a)T
❑y. �na
All roofs shall be inspected prior to any roofing material being
will the a bean, or rutum buildin Occupant m
pp B p equipment or swim which
If a roof is installed without first obtainingan inspection, I agree to remove
P
. tnus air contaminants ss defined by the Bay Area Air Quality Management
District?
all new materials for inspection.
1
❑Yes LIN.
1 have mad the hazardous msuriaiso quirements undcrChapmr6.95 of the Califon
.is Health&SufetyCode, Sections MMS.25533 and 25534.1 umicnend that ifthc Wilding
does not cumendy have t hems ny that it o m oesporeeloiny to nooly the mcupaaapppt of the
mqunneents us(bcnrF,bmr
Tofaccnificatrortx�ap PY%
Signature of Applicant Date
I/ jDaaid'
All roof coverings to be Class "B" or better
Owner or aamonnrg5 ,