08040018 CITY OF CUPEATIIVO �*4ffii t+ '�'°r '%'tx-�."� + '"• -'
BUILDING DIVISION PERMIT kCONTRA CT(Qii INFOItMMA TIO1V"
BUI DDRESS: PERMrr NO.
545 CUPERTINO RD TBD - TO BE DETERMINED 08040018
VNER'S NAME: PSU.M ISSUE DATE
07/08/2008
NE: SANITARY NO, CONTROL NO.
ARCHMCrIENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
IOp LICENSED CONTRACTOR'S DECLARATION Job Description
I hdeby affirm lost I not IisvM Clu under provisions of ter 9(commencingP
;jE -STAY SNGL FAM RES W/BASEMNT 5, 767 '
in full fora and ened. S
z2Az DOW uc.•
f Dato Contractor
ARCHITECTS DEOI]1R
; U 1 nd my plus Ball upublic rtcod,
Liccond Pmfuaioiu /
O - OWNER-BUILDER DECLARATION
i f 1 hcmby affirm that I am exempt form Ne Contractors Licence Law for the
i
20 following moon.(Scclton 7031.5,Business and Professions Code:Any city or roomy
3_ which rtquirca a permit to construct,alter.Wprow,demolish.or mpair any strtmtum -
_Zt prior to is issuance,arca mquima the applicants forsuch permit to file a sigmd summon,
[
ma that W is Bccnmd pursuant to the proviaian,of the Contractors L usome law(Chaptd 9 Sq.Ft. Floor Area Valuation
11-$ (commencing with Section]0013)of Division 3 of the Business and Professions Code)or $865000
e3 that W ts nsunp,thuefrom and the buts for tW alleged eaemptian Any violation of
semen 7031.5 by any applicant for a pend,mbjccu me applicant to a civil pcvlty of Number Occupancy e
notoraethanBKhandedddlus(S-Im 32616035!F� ane T P Y YP
❑1,a miner of Ja propmry.a my wployaa with xgn u thou ale mmpewtion,
W PPnof�oru Coalk:TW ccuumnaltme.L�Ls door.[apply in....of Required Inspections
property who builds or imp rove thvmn,and who docs such work himnel f or through his
awn employsca,pmvided that such improwmdua art not intended oroRered forsWa If,
bowevu,the Wilding or impmvema,u sold within am you of completion.the owner-
builder will have that l urdut of proving that W did not Wild or improve for purpoa of
ssleJ.
Cl 1.u owtur of thin pmpeny,am conclusively contracting with liaised contractors to
construct the pooled(Sec.70ad,Business and professions Cade:)The Contractors U.
rove Law dura out apply in an owns of property who Wilds or improves tW men,LAW.
who contracts for such prajeda with a contradar(s)licensed pursuant to the Gonuac,ors
Lleena law.
Q ltaneacmp,undd See ,BBPCforthsmama
Date
WORKER'S COMPENSATION DECLARATION
I W,cby affirm under porosity of perjury oro of the following declan0ons:
Q I ham and will maintain a Certificate of Consunuo xlf-ilium forWmkcra Compch.
union,u provided for by section 3700 of the labor Code.for the performarta of the
work for which this permit is issued.
Q 1 ban and will maintain Workefs Compensation Insursua,as m,dmd by Schon
3700 of Ne LaWr Cade,for the perloomrmm ofthe work for which this permit uivued '
My Workeh Compensation alumna curio and Policy number tae:
Candor. S'j 1d�i f7!(-9 Policy No.: 01144lQ 7
FlFJCgI GTEOF EXEMPTION FROM WORKERS
COMPENSATION INSURANCE
(This elm nod rot W completed if the perm,is film huttthed do0an(SIO)
orlma.)
1 artily that in the perforst.of tW work for which this permit is issued.I shall not -
cmPloY sty Noun in try mammrro as u become subject to the Workers'CompensaJon
lax of California.Dau
Applicant
NOnCE TO APPLICAN..IL afmr making this Cenificau of Exemption,you should
become subject in the Workcrs Compcnssuon pmvisiona of me labor Code.you mum
., z forthwith comply with such provisions or,ms permit shall W damod mvokcd.
z `" CONsrRUCrION LENDING AGENCY
[
r+ IWrehy drix that thertsacosutmctinn lending agency for the performanepf
C> Jin work for whim this permit is issuo4(Sod 3097,Civ.C.)
0 Lsndcrs Name
z L cn&ez Addmu ,
V O 1 mmify that 1 haw rt>d the application am state this do aWw Wcommum is
[L Hconed es to I agcomply wits all city and C."odlnar ms,and arae laws mlatina to
O V Wilding construction,and botchy addition mpmaentdlws of this city to corer upon the
a
b.-mentioned pnipeny for inspemoo purposes
pal, (Wc)Agra to can.indemnify and keep has on Oe City of Cupertino against
na rA liabllitim judgmens,emu and expetucs which may in any way aiutuid City
C)z m PLICA T of the R!fTANing of ms permit
r APPLICANT UNDERSTANDS AN WIC pM WITH ALL NON-POINT Issued by: Date
SOURCE REGULATIONS / / /
100 Re-roofs
Sign e�ppllLLl✓Gantreetor y p -
HAZARDOUS MATERIAL 9 DISCLOSURE Type of Roof
Will the applicant m futum Wilding Occupant nr9oorhandlc huardou material
as dUned by the Cupedoo Municipal Code.Chapter 9.12.LAW the Health and Safety
.seeams zss3z(a)]
❑Yu N9
All roofs shall be inspected prior to any roofing material being installed.
�
Will me applicant m forum Wilding occupant um Ndipmwl or dcvim which If a roof is installed without first obtaining an inspection,I agree to remove
ewer huadnns air communi ms a defined by me Bay Anse Air Quoddy Management all new materials for inspection.
QYu 60No
I haw read the Wold num rid.rquirememaunilcr Ch 95ofineCdifor-
L.smody
@SdnyCode,Sations 235W,25579 u`u1255 rsund thuiftW Wilding
haw•tenon u y rt ility to notify the arupsut of the
ta which mus e �a Cusif�m Waco,pyJ
Signature oBApplicant Date
owner ar ant r ,cent — All roof coverings to be Class'%?."or better
— L