07080095 CITY OF CUPERTINO ei yy • w.r•�� a -
BUILDING DIVISION PERMIT �t.'('�1rlTlttl. x'!CZT�"t1�T1'' R`1l!IA,TIIs
k s.`d4 E.,. .`ht jx .A�`b.,b \ 21 "`, $�•-i:.
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BUILQIT4`V B07080095
R.ESTLINE DR TBD — TO BE DETERMINED PERMIT
WNER'S NAME:C PERMIT ISSUE DATE
SANITARY NO. CONTROL NO.
ARCHIIECl/ENGINEER: 708 ' ADDITION—FAMILY RM, BLDG BUILDING ELECTPER O
PLUMBMECH
o o LICENSED CONTRACTOR'S DECLARATION r
e V 1 herby affirm than am nxved under previsions of Chapter 9(commencing Job Description
e with Section 7IXk),of Division Sarcine Business and Propound.,Cook,and my license is
t�Bi in full force and effeeL
p 3 License Clara Lls.If
c Dam Commuter
;q ARCHITECTS DECLARATION
a 1 understand my plans shall be used u public records
id
C Licensed Professional -
5 OWNER-BUILDER DECLARATION
Con clo
E 1 beaby alarm that 1 I. exempt from the Ccudowsr'a I:An,c Law for the
O e following moan.(Sadat RD un Business and Pmfdmms Cook:Any city or roomy
3� which.qui issuance,
n Permit reconstruct atm.Impmw,h Permit t ver repair any saunmL '
u Z, prior ro its ccrowd moment to the lbe applicant(orthe sucCom Permit to Lie ,Law atlomem
5� (comm is licentod pursuant 7000)of Division
3the eBusiness
uumM1Limmerstw(Chapmr9 Sq.Ft.Floor Area Valuation
,at(commencinghexampt therefroon m
and
the
harm f rth al aged easand Profession,latde)ion or
Net he u exmpt them(mm end Ne basis far the alleged exemption.Any violation of
Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of APN Number Occupancy e
not mare than five hundred dollars(SM. P y +1f]P
0 I,a owner of Ne property,Or my employees with wages,u their sole compensation,
will do the wort and thesvucture b natintended mo02rea forsale(Sec.7044,Business
and Profassm.Code:The Convectors Liame Law dom ret apply to an Owner of Required Inspections
propeny who buildsorimprows themen,andwho doessuchworkhimselfor through his
man employaa,pmvided thatsoch improvements are not mmMW reoffered forule.IL
however,the building or improvement is sold within can year of completion,the owner.
builder will have the harden Of proving Ne(W did Out build or improve for purpose of
sale.).
&d.as owner of the property,am exclusively contracting with licensed convectors to
construct the project(Sec.7010.Business and Professions Cotler)Tbe Contractors U. .
anx law does not apply men owner of property who builds sur improve theman,and,
who contracts for such projects with acv m encr(q licensed personal toren Comomors
Lice.Taw.
❑l am ue1 under See. �,yam, B R P C for this moon
weer
DECLARATION
I hereby aBimr under petvvy of p do,one of tha fallowing declummun
El
I marc One will meintsin aCertifialo ofConxnt re self-inanm for Workers Compen-
.don,as provided for by Section 3700 of the labor Cook,for the pe fmmamm of not
work for which this Permit is issued. ,
❑1 ban sod will maintain Worker's Compensation Insurance,as m mind by Section
3700 of the labra Code.for the performance of the work for which this Permit is loved.
My Workers Compensation Insumem carrier end Policy number are:
Cartier. Policy No.: _
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
Indirection need nut be comptead if the Permit laforonc hundred dollars($100)
or leu.)
I artily,that in the performance or N)work for which this permit H bound,l shall not
employ any person loan m m)sobject
m,.&sw mthe Waftm'Comp r,"den "
Laws of California.
Exemption,you should
become subject to the Worker's Computation provisions of the Labor Own,you must
.J O forthwith comply with such provisions or this permit shall be doomed reversed.
,'Zs,'-' CONSTRUCTION LENDING AGENCY
I hemh aMm rho dam its construction leadin agency yfor the
perfurmencm of
C4> thus work for which this comm Is issued(sec.3037,Civ,C)
W�Q Lenders Nam)
Q z
Lender's Addmo
U Q I coolly Nu I have rad this application and sum do,the above infmmatim is
U. comets mets I sgred u su
to comply with all city and countY aollmosand m laws Mlaring 10
Q 4V^ building convection,and hereby avmorix representatives of Nie city 0o color upon ft
[i7 above-ammims d property for inspection purposes.
(We)agree to saw,indemnify and keep harmmu the City of Cupenina against
o-y co) Iimilid"JWgmenu.cosu and expmta which may in my wayucom,against mid City
V Z in consequence of dt gmndng of this permiL J (�
AP LI ANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINTIssued by: Date
SO
^ �' ��' �'�I 2s:
s Re-roofs
Signature mAppliunVConuumr Gas,
HAZARDOUS MATERIALS DISCLOSURE Type of Roof
Will f applicant or fume building oceupantooro or handle haauaem malotisl -
az doped by the Cupertino Municipal Code.Chapter 9.12.and Ne Health and Safety
ode,Seniors 25332(a)T
Cl Ya 6?�a All roofs shall be inspected prior to any roofing material being installed.
Will the applicant or future building occupant sax equipment or devices which If a roof is installed without first obtaining an inspection,.I agree to remove
emit huudous air contaminants ss defined by the Bay Area Air Quality Management all new materials for inspection.
DisuictT
O Yn Q�a
I haw mal the hreard0us materials requirements underchap mr6.95 of cit Califor.
nine Hul"SafctyCode,Sccdmu25505.25533u B5N.Im .c muifdtbuilding
om�d net cutren11 haw a tenant tho it u my resNo hilitY to rtotify cit=UPMC of cite
nuwhichmusmet pnorto LuvanceoIn Covilkws,of oecvpmq. Signature of Applicant Date
Dow All roof coverings to be Class"B"or better