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CITY OF CUPERTINO-='moi'£"
CONTRAGTnR;INFOIiMr1T
BUILDING DIVISION PERIVIIT
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BUILDING ADDRESS:
CARY QUEEN
PERMIT N0. 06050201
22830 SAN JUAN RD
OWNER'S NAME:
-
PERMIT [SUE DATE
09/05/2006
E:
SANITARY NO. CONTROL NO.
ARCHr ECDENGINEER:
BUILDING PERMIT INFO
BLDGO ELECTO PLUMB MECHO
LICENSED CONTRACTOR'S DECLARATION
Job Description
1 hereby alarm Nal 1 sm Beamed under provimana of Chapter 9 (mammcming
with Section 7000) of Divi m.3 afthe Bunineas and Protesti.. COCA. and my He... is
in fell 17.mamd.frect
KOI POND/FOUNTAIN FRONT YARD
License class, 1"'"
POOL/SPA EQUIP NOT TO BE CONNECTED TO SEWER SYS
ARZ EC -S DECLARATION
I understand my plans shall he used As Public records
Lw.rucd Professional
OWNER -BUILDER DECLARATION
I hemby alTum that I he asempl from the Camrocmea License Law for Um
following mamn. (Section 7031.5. Beebwss and Prortssions Code: Any city or county
.
which requires • permit to --L 11W.. Armen. demolish, m repair any stmmum
prior it its issuance, alae requires the applicant far such permit to His, a signed statement
Lre, ch.pwr 9
Sq. Ft. Floor Area
Val0 a�5r0 0 0 0
4
the he Is Renaud pursuant us the pmddons of the Contractor', anse
(commencing with Section 7000) of Division 3 of the Busineas and Profhsians Code) m
that he is Comp, Huamfrom and the basis for His alleged exemption. Any violation of
Section 7031.5 by airy applicant for a permit subjects the applmsot w a civil pcnahy of
APN Number
Occupancy Type
w, ream Dun five bundrW dollars (Sm.
34221030.00
❑ Las owmr of th e property, army employees with wages As their tate emmPanssdon,
Required Inspections
9 P
dlha s Budnw
Leaded orae,
will do Hueadoes
Him,
and Professions Cade: The Conmsacan, License Law doh ret apply tf an owner of
C he coo me. .ppiy.he to
prowho Wlprovidmprovas who daesamhende work himselfarthrough his
ve are not intended for We.IL
bt improvements
own employees. provided Nee Impm
man am
of completion, the pwmsf
ld wit mpleeO .
however. Ne building car Improvementg mid
np
did ane y
a d
builder will have Uat burden of proving tut k did ret build or improve (m purpose of
sale.).
❑ 1, ns owner of Ne Property, atn exclusively cOmrw mg with Hemmed cum actors in
consents, the prefer, (Sec. 7046. Business and prornm ns Cade:) The Comeactnes Li.
Oman law dam no, apply w an owmr of property who Wilda or improves theman. and,
who contracts forsuch projects with a cmlVamer(s) Seemed pmammt In dY CormAter'3
Lic-an U-
❑Iatnexemptunder Set . B A P C rat this reason
ooa +ltJe G
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1 hereby affirm under penury of perjury arm or dee fallowing declamtia s:
[him and will maintain aCenificam of Cansamw self- asum for Worker's Compen.
radon, as provided for by Section 3700 Of to Isbm Cade. far the perfonearxat of to
work for which this Penni, is ihued.
❑ I Have and will maintain Workcr's Compensation Insurance, as required by Section
,
3700 of the Labor Code, for tat performance of He work rat which Nie permit B iasusd.
My Worker's Compensation Insurance carrier and Policy number art:
Cartier. Policy No.:
CERTIFICATE OF EXEMPTION FROM WORKERS'
,
COMPENSATION INSURANCE
(Thu acetion need not W completed RIW permit Is foram hundred OHM (51001
alms.)
I Certify that in the performance of the work for which this peresh is haded, I shall not
employ any person in any manner so etMo/rIsubjcm w thatWorkeri Compensation
Laws of Califomit
of Exemption, you should
become subject w the Worker's Compensation proviai0h13 of HuO ISWr Cade, you most
forthwith comply with such provisions or this Permit shall he deemed ranked.
LENDING AGENCY
HisCONSTRUCTION
1 heathy Wt fere u a c lending agcmy fm the perfurmmtt of
chaffine
d (See. 0
e the woe for which this permit h trued (See. HAI. Or. C.I
Lendes Name
'
landees Add^••
I certify that 1 have read this application and sum Hurt the AW" information is
carted. I agree to comply with all city and county ordinances and state 1.. rtlating to
building consuuction, and hereby authorise mpresenurms or this city to enter upon the
fj
man-ms,judgdpropcnt (an inspection Purpowhich
4 (We) agree to save. indemnify and keep harmless the City of Cupertino against
m.
> incoisegjne of theaatsind es tense which may In my wy.cauegainsuaid City
of Huegrantingof this per mit
.
� APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON -POINT
A APPLICANT
Issued by: Dale
SOURCE REGULATIONS.
-
e
Re -roofs
T Of ROOF
Type
Signature ofA sanvCanmmtm Dtm
HAZARDOUS MATERIALS DISCLOSURE
Will that applicant or Human Wilding oaupantswm or handle hemdous material
a defined by the Cupertino Municipal Cade. Chapter 9.13, and the Hhltl and Safety
da.3ection 355320)7
All roofs shall be inspected prior to any roofing material being installed.
[]ym 0 N
If a roof is installed without first obtaining an inspection, I agree to remove
Will the applicant of future building occupant on equipment or device which
emit havrdnus air comminute, as dcRmd by Hue Bay Am Air Quality Management
all new materials for inspection,
DhV CTP
❑yca ON.
1 have mad the hanedous materials mquimments under Chapter 6.95 of the Califor.
nu Hc.lthA, SafctyCodc, Seetions 25505, 35533 and 25534.1 undcnund Had lfthc building
dos ret curmmly hoe a tenant On It is my respomihility as notify the mcupmt of the
mquiremcnetwhlch most W me, prior in annuce ofaccrtirmate oroccupaneg
Signature of Applicant Date
Dam