08040215CITY OF CUPERTINO
BUILDING DIVISION PERMIT
CONTRAC'�TOR INFURMATIO,N'::
BUILDINGA DRESS:
107�U ALDERBROOK LN
D R DOMENICHINI
PERMIT NO.
08040215
OWNER'
SANITARY NO, CONTROL NO.
(408)691 -3283
ARCHrfEC9/ENGINEER:
BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
LICENSED CONTRACTOR'S DECLARATION
O I
Job Description
P
I herby grim grim Nat I @m licensed under provisions of Chapter 9 (commencing
with Section 70M) of Division 3 of the Business send Pmfessiom Code, and my license is
REVISE COMPSHNGLS INSTD OF CONCRT TILE
to immcC ea
lasndeff Ueg
ORIG #07070255 THE REVISION AFFECTS STRUCTURAL —NO
Date
ARCHITECTS DECLARATION
NEW PERMIT
1 understand my Plans shell b used as public records
Licensed Pmressioml
OWNER - BUILDER DECLARATION
1 bemhy cif[ n that I am tumpt from the Commons License Law for the
following mason. (Section 703 1.5. Business and Prefessiues Cade: Any city or county
which requima s permit m consumes. alter, improve, demalksh, or repair any swnure
! prior to its issuance, also requires lM appliant for such Permit to file a signed statement
is licensed M NC NC Conuactsr's Uceme Law 9
Sq. Ft. Floor Area
Valuation
Nat he pursuant provisions of (Chapter
$0
(commencing with Section 7000) or Division 3 of the Business and Professions Code) or
! that be is cumin therefrom and the basis for dte alleged exemption. Any violation of
36920047 q.6; Number
Occupancy Type
Section 7MIJ by any applicant for a permit subjects the applcam, he s civil pmany of
non mmthn five hundred dollam(S50o).
El,asownm of the prtspmty, or my emplayem with wguu Nev sole compensation,
Required Inspections
wiRdathework ,andtheasmumumti.Mndedmoffa ferule(Sec.70N,Business
and Phefeaitsm Code: The Canuacsors Liaise Law does rot apply he an owner of
-
progeny who Wilcisco mprorm the con, and whodoessuchwork Eimalforduough his
awnemploynes, provided that such improvements art not intended oraBered forsale. If.
however, the building or improvement is held within one yea of completion. the owner.
Wild. will have the b rden of proving dui he did nos bib or improve for purpose of
tale.).
�u owner of the Property, w exclusively contracting with Raised commas he
eomnmtt the project (Sec. 7014. Business and Pmftsda= Code:) The Conrraesurs U.
come law dam not apply to an owner of pmpwy who builds or improves thereon. and.
who contracts forsurh projects with a contractor(s) licensed pensmnt as the Contfxcmrn
License Law.
E
1 herby affirm under penalty, of perjury, rn of the following declarations:
—, 1 hs.e and will maintain aCentiGmu of Comer to self -inure far, WorkersCompwm-
cation, as provided for by Section 3700 of the Labor Code, for the performwa of the
work for which this fermis is issued
Ef f have and will maintain Workers Compensation Lumrance, as muquimd by Section
3700 of the labor Cade, for do pmformrce of the work for which Nis permit u issued
My Workers Campenuion hu mosm earn. and Policy, numbs H:
Carver. Polley No:
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(This section minced hot be c uspmed ifds permit is fore. hundred dobars($Iw)
or less.)
1 certify that in dm performance of thee work for which this permit is issued 1 shall roll
employ any person in any nunrwast b rsu jeans the Workers' Compensation
A'-
Laws of Califomie.
NOTICE TO APP CANL If, afeT making this Cenifsam of Eameption, you should
became subject be the Workers cmeNroatimi provision of the Lobar Cade you mum
' foMwiN comply with such provisions or this permit shall M deemed revoked.
'
CONSTRUCTION LENDING AGENCY
' 1 hereby aRinn that thort is construction lending agency for the perfermatue of
s
work for which Nu permit is issued (Sec. J097. Civ. C.)
30
lenders Name
Le
lrndeh Add=..
1 I citify that 1 have tad this applicants. and nuts dear the above bforoutiun is
' monmL I agmc a comply with all city and county ordinaries, and sum laws mining to
l
Wilding construction. and hereby announce mumunsdves of this city to enter upon the
I aMVe- mentioned property for inspection purposes
(We) agree b save, indemnify and keep harmless the City of Cupertino @gai=t
..
j itim.Judgme costs and which may in try wayamue against said City
//fit
of this Ir
inscheme. the 1.
of nos grantin1 of Nu
A
LICA T
D WILL i APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON -POINT
..[`-- \�— �ttwt. (�/��/ ///
Issued by: Date
SOURCE REG 0
��ln
e#1 ��
Re -roofs
Signatum of Applianv onuacwr �T Date
HAZARDOUSMATERIALSDISCLOSURE
Type of Roof
Will the applicant or fusum building necupu uN
t them or handle haous ma¢nal
as defined by do Cupertino Municipal Code. Chapter 9.13. and the Health and Safety,
caa. Seedon 25532(.)? ❑ym fa
All roofs shall be inspected prior to any roofing material being Installed.
-Will Nc apish rsnl or future Wading oceupanl use equipment or devices Mich
If a roof is installed without first obtaining an inspection, I agree to remove
hevardom air conuminru as de0rted by the Bay Area Air Quality Management
all new materials for inspection.
District
P
❑Yin 1No
I have mad the haurdout mat habmquiumenu..k,Clupterd.95ofthcOlifor-
nu Heal" SafetyCede.&do.25505,25533 anal 35534.1 undenund thanifthe Wilding
does not eo mody ham a usual. this it's my responsibility to ratify dat camper, of de
requi ts whiC um b rocs peel b issumce of a ecnifKm of oempaney.
�� �_
Signature of Applicant Date
/7 � �Jg
All roof coverings to be Class '%¢ or better
or authenrsd @ t Dom