08070147 CITY OF CUPERTINO
BUILDING DIVISION PERMIT kCONTRAC'TQRINFOItMATI,gN�
BUII,L}IN yD RESS' PERMrr NO.
LV1� HYANNISPORT DR TBD - TO BE DETERMINED 08070147
NER'S NAME: PERMIT ISSUE DALE _
;
SANITARY NO. CONTROL NO.
ARCHRECrfFNGINEER: BUILDING PERMIT INFO
-BLDG ELECT PLUMB MECH
u 0 Q LICENSED CONTRACTORS DECLARATION
IIhemby affirm that I son Ilamm
ad ander provisions of Oiamer 9(commencing Job Description
_ w11hSeCuom70W)ofDivbmd3oftheBasn.and PmfessiuvCode.and mylkenzis ADD 263SQ ADD OF' MSTRBTH&WKSHOP & RMMDL
J N oIYII lama N net
5qz Lleem ata r Lk.g o�3 (E)MSTRBTH
,�,ppwwwyo D.m ARCHITECTSDECLARATIO ) ' INTO WLK—IN CLST NOTE: NO DECK ASSOC W/PERMIT
W< 1 understand my plans Nall W used as public records
n
g Licensed Profrssianel -
OWNER-BUILDER DECLARATION
C.nT10N
1 hereby M.on 1 am exempt from Ne Conuad Co License Law for dm
r O o following maza.(Secdon RD I.S.Busirzva sed Professions Calc:Any city or County
$�
which mquims a pmmit in canswcL allu.improve.ncmollrh,or mpair anY rtructum
_Z y prior m its iroua d f orwamgoims tW applicant for such pmmit m License
a w s hi mem
6 thatheingmc Sud 7to ft 0DO)pmviaion3dm Contraczrl Lkera¢Law(Citaptm9 Sq.Ft.Floor Area Valuation
ee5° that Its C. g pt $65000
yo 3 Inst io u eumpt anmfmm and We basis far be alleged exemption Any violation of
.1 Chad by airy applicant fora permit subjects Oe applkm b a civil penalty of Number
�t roam War ties haMmd dollars atom. 35608002 � Occupancy Type
❑Luowmraf Nn propm[y.amy employes with wagnM Ne'r zlo compensedon,
will do Nework,and We zumme Is mminlendcd croffared forsake(Sec.7064,Butimm
am Professions m
Code:The Co ,acmes Ls, m
ieLaw doer act apply ,n owner of Required Inspections
property who builds,k tmpmwn Wvcom who doessudswrkhimself Uwugn hu
awn cariployces,
provdedthat inch i wn nts tienot intended or edf if.
hw .NeWid aimpromntiswidWWaofCopledOmoner-
Wilder MB have did bodies of proving that W did act Wild a improv forpurpose of
tile.).
❑1.as owner of er psopcny,and eaelusively contracting wild Iicemzd contracts W
cioswct Oe pmjem IS..7(144.Build.and Professions Cade:)The Contractors U.
cc=law des not apply to in was of propcnY who builds or improves dreea t.and
who Contracts for inch projects wild a conuzbr(s)Ikemzd parzant w the Coatramors
Us.Law.
lammemptandm See .B&PCforthommon
Dan
-
WORKER'S COMPENSATION DECLARATION
1 hcmby affirm under penalty of perjury arc of the following dalaraiorvt
❑I haw and will maintain a Certificate of Consenuo self-imamfmWorWaCompcn-
Wind.u province for by Secdon neo of We Labor code.rm die pertonceme of don
work for which this pewit it iafed.
❑1 baro and will maintain Workers Compensation ImwarCe,as mgatmd by Section
37M mfthc labor Code.for We performance of We work for which this permit It bound. '
My Workers Comp`ensuiem Insurance Carl"roof Policy nordbar art. ^
Carrier. 5 �C. V7 4_ PolicyNo.: 1 t
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
Obiszmlon rid mot be cmnpiamd if the pcon,Irrormm haMmd dollars(SIM)
or Intal
1 certify,that in We performance of the work for which this permit is issued.I shall not
employ,any person in any mamerz as W bawne subject in do Worhrs'Compensation
laws of California Dam
Applicant
NOTICE TO APPLICANT.If,!fir making this Ccni iicam of Exemption,you Clock,
bCpme ryonci,W We Worker!Compensation provisions of WC Ichor CNIC,you am
Oforthwith comply with rich provisions m this pCol t shall EC deemN moolied.
'zJ N CONsmucnON LENDING AGENCY -- _
[-+ I hemby affirm that Oee'tsa conssnedon lending agency for the pirformanco of
pS i em work for which this pemut is issued(Sec.3097,Civ.C.I
0 Landers Name
oti. z Icn&es Milmss
U C) I Certify Oat 1 haw cad Wis application W state that Oe above information u
LL Cdo,cs 1 agmn m comply with all city and County on inarcnt and sale Iowa relaims to
.C) Wilding Constriction.and hembyamiarertp..Wivoi of lhucity to cownpna the
W ahnvam funnedmcd proprny for WpeNaa puryaza
(„i 4 IWO name w tow,indemnify and keep northeast die City of Cuperdrm against
ti h in Coitim,jadgmenu.cottsand expense witch may in any wyamae against mid City
V z inconsequence of OC granting of this permit
APPLICANTT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT Issued by: Date y
Re-roofs
srgnuam or ApprmaHAzA ous MATERIALS DISCLOSURE D.m Type of Roof
Will the applicant or futate Wilding occupantnore or bandle 1maNans maorial
u ncRncd by die Cupertino Municipal Conc.Clamor 9.12 and the 11nt1O and Sally
Section 25532(a)?
❑Ynt )6No All roofs shall be inspected prior to any roofing material being installed.
Will dm appficam or fumm Wilding occupant use equipment or dovtiCes which If a roof is installed without first obtaining an inspection,I agree to remove
emit havaNnm it Contaminants as dchned by tic Bay Ams Air Quality Management all new materials for inspection.
District?
0y. VN.
I hero real the hi aNCus mamrialsmquimmems umfer Chapmrti.95 of We Cation.
nuHmIti18Safcty Cade.Sm=2550S25533aad25534.1anhnsts ifdn Wilding
does not curmndy hew a mans des it or my mspomtbilily m rwdfy the occopzt of the
Fntaw,nmaNWmetmarmis aaarac raearalIamaay. Signature of Applicant Date
k`F "y All roof coverings to be Class'1}"
Owner or out entree sacro .Dao' g or better