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CITY OF CUPERT[NO
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BUILDING DIVISION PERMIT
,CON RWCCTOWIIN�TORMATION
BUILDING ADDRESS:
6c;2 RgTnng PARK rT
THE WINDOW BROKER
PERMIT NO 04010017
ER'S NAME:
FERMITLSUEDATE
ENGELMAN
2
DNE:
SANITARY CONTROL N0.
ARCHITECT/ENGINEER; -
BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
LICENSED CONTRACTOR'S DECLARATION
70b Description
I hereby affirm that 1 am licensed under provisions of Chapur 9 (commencing
with Sccmm 7") of Division 3 of NC Business mProfessium m license is
in full fume n efr'a.C` �'
License Cl Lb!N
WINDOW REPLACEMENT
_
Dau Cu
ARCHILTS 0 ATI N
I and mY plan;ahAllWrecd a crccandi
Licensed Professional
OWNER -BUILDER DECLARATION
I hereby affirm that I em exempt from the Contuerofs License Lew for the
following mans. (Sccdon 7031.5, Business and Professions Cole: Any city or county,
which requires a permit to consumer, alter, improve, demolish, or ¢pair any structure
prior te its issuance, alesmquims theapplicantforsuch Permit to file&signed statement
that he is licensed promantw the provisimu ofthe Comrxmr's littve Law (Chapter 9
Sq. Ft. Floor Area
Valuation
(commencing with Section 701 of Division 3 ofmc Business and Proreuimu Cole) car
Net he it exempt therefrom and IK Esau for the alleged exemption. Any violation of
313�I92D6i@er00
Occupancy T '
P Y yPe
Section 7031.5 by any applicant for, permit subjects the applicant to a civil Penalty of
not mom Nan five hundred dollars ($500).
❑ 1, As owner of the propeny, m my employees with wages As their vele compensation.
will do the work, and to structure is not intended or offered (orale (Sec. 7004, Business
Required Inspections
and Pmfealow Crede: The C.mradofs Littme Law dors not apply to an owner of
prapeny who builds., improves div eon, and who d,es aueb work himself., thmuSh his
non employees, provided that such improvemrnu are not intended oraRered for sale. If.
however, the building or improvement is sold within ane Year of completion, the owner -.r•-_
builder will have the burden of proving that M did not Wild or improve for purpose of
Asia
❑ L a pwner of the gnntnemrs i.
and ep lessirng with:)The
..:
`' alt,mos
Sec.property, ,B sines
the pmjeat (Sec. 7004, Business and C
Coe:) The Comncton, Ld,area
hum dms raupply m m oatha of proper( who is
La rty whopts ca thenconCurve.
pur uant to
ress.who
for such projacu with a conuumr(q liccved punuenl to du ConuacuYs�
sed
i,License
se Lu`
Law.❑lam
exempt under Sec.-,BhPCfor NisHE
Data
I
WORKER'S COMPENSATIONDECLARATION
1 hereby Affirm uMer penalty of perjury one of IW following deel,nti.nr.
I have and will maintain a Certificate of Consent o se1FLu me rat W.rke's Compen.
satlon, As provided for by Section 3700 of the Labor Code. for Be p,Nmmance, of du
work for which this permit is issued.
❑ 1 haw and will maintain Workels Compensation Insurance a required by Secdon
3700 or the labor Code, for Inc Performance of the work for which this Permit is issued.
My rke s m soon IesI1MT n uj� Policy number
C 'er k f Ia0Rs7 No.: Z
CERTIFICATE OF EXEMPTION FR KERS'
- COMPENSATION INSURA
(This section need not W completed If the Permit Is forms, hundred dolls, (Slip)
or leu.)
I Caniry that in the perfarmance of the work for which Iiia Permit is mated. l shell not
employ any person in any manner an As ka become wbjecno the WmkeW Compensation
Laws of C,lifomia. Data
Applicant
NOTICE TO APPLICANT: If. After making this Certificate of Esemption, you should
become subject to the Worker) Compcesa0an prevision of the Labor Code. you in"
forthwith comply with such provisions or this perm it Mall W deemed revoked.
CONSTRUCTION LENDING AGENCY
I heathy affirm that Inure is contraction lending agency for the performance of
that work for which this permit is issued (Sm. 1097, Civ. C.)
Lender's Name
Lender's Address
1 mnify that I have mad this application and state that the chow information u
corms, l agree to comply with all city and county rminanas and sure laws misting w
building construction. and hereby authorire representative plans city to met upon the
shove -me Property for purposes
(We) agree to caw, indemnify and keep harmless the City of Cupcninr against
expenses
judgments. ex pensesWhich may in any way ¢trot Againat aid City
Iiaconarquen
eofthegranand
in wnaquenec of the granting of this permit.
APPLICANT UNDERSTANDS A/NND� WILL COMPLY W/I17 ALL NON -POINT
Issued by: Date
SOURCE f LA�"
`
Re -roofs -
Type of Roofwill
•Dye �-'
r,ofApphgAHAZARDO D,te
HAZARDOUS MATERIALS DISCLOSURE
the a t or future Wilding d.Chip stere o. ixodic maudal
Cale BasutoAn
efined by the Cupertino Municipal Cade. GhAPre( 9.11. And the Hcala and SAferyo,
Sccdon 155314)?
❑Yes )ZI.Will
All roofs shall be inspected prior to any roofing material being installed.
If a roof is installed without first obtaining an inspection, I agree to remove
the a litant or future buildin occu am us
which
pp 6 p equipment or
Maas
s air conuminanu a defined by the Bry Ama Air Quality Managcmcnt
all new materials for.inspection.
❑Ya �0u
1 have read the harudm Mnabnalsraquim unuunderChapur6.95oftheCalifor-
niaHcala&safety CuM,Sa'am255r15.15531 And ndc dthis i(du Wilding
data not c no, haw a tempt, Nat it is my msPonsim14Y t fit, the ceeupam or are
mqulre tswhi� muuWmetpnorwi u or.Ccm) .roc p.cy.
Signature' of Applicant Date
All roof coverings to be Class "B" or better
Owner um i.il
or Magent Data
Y�Yoij
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CITY OF CUPERTINO
'�"'RY'?'✓'" ""8+
BUILDING DIVISION PERM `"CONTRACP,nTiINFOtuvIA
N
BUILDING ADDRESS: _
THE WINDOW BROKER
PERMIT NO 04010017
OWNER'S NAME:
PERMIT ISSUE DABS
E
NE:
SANITARY N0. CONTROL NO.
(800)639-4527
ARCHITECT/ENGINEER:
BUILDING PERMIT INFO
BLDG ELECT PLUME MECH
0 0 0 0
LICENSED CONTRACTOR'S DECLARATION'
JOb Description
Job
I hereby affirm shat I am licensed under pmvisiom of Chapter 9 (commencing
with SCCIIon IOW) or Division 3o( the Busines�s ra1d Pmfcxsiom,r� dyy��Lny m license is
in mu mane an erceer.G
LiccnmC L ler�v Y 7X
WINDOW REPLACEMENT
Date Con r
ARCHI Cr$ D RATI N
1 ullbolind my plan i hall be used s is onards
Licensed PPr\offessianel
OWNER -BUILDER DECLARATION
1 hereby a(Orm that 1 am exempt from the Contractor's Lkenm law for th
following mason. (Section )(131.5, Business and Professions Code: Any city or county
-
which requires a Permit m construct. nor. improw, demolish. at repair any mrucmm
- -
pdor at its issuance, also requires the applicant for such Permit file a signed stamment
Sq. Ft. Floor Area
Valuation
that he is licensed putsuano the provisions of the Contractor's License Law 9
u
_
(Comrrencing with Section 1000) of Division S of de Business and professions Code) or
.
that he is exempt themfr0m and the basis for the alleged exemption. Any violation of
3 @RI52,b61her 0 0
Occupancy Type
Section 1031.5 by any applicant for RMoor wbjects the applicant o a civil penalty of
not more than five hundred della. 15500).
❑], Is owner of the prefatory. at my employees with wages u their sok Compensation,
Required Inspections
will do the work, and the structure is not intended or offered for sale (See. Illdq Business
and Prefesaiam Coac: The ContraetOM1 License Law does MI apply to an owner of
peperty who buildsmrimpmves thereon. and who doessuch work himaelf or through his
.
own employees, provided that such improvements are not intended oroffemd far sale. If.
however. the building or impmvcment is mid within oro you ofcompletion, the owner.
builder have the burden of proving that he did not build or improve for purpose of
I
.)will
sale.
❑ L as owner of the property, am exclusively contracting with licensed contractors to
'
Construct the project (ECC. 10a4, Basin. and Pro(eaalON Cd,:) The Contractors LI.
1
cense Law does not apply to an owner or property who builds or barrow thereon, and
who contracts lar such projects with a comm ctor(s) licensed pursuant to the Contractor's
Lie nal Law,
-
1 am exempt under Sec. B A P C for this moan
s
Owner Data i
_ `I
WORKERS Callyof Ay. DECLARATION'-
1hereby alnnn under penally of perjury one of Ne following decimations.
l� '
❑Thaw and will maintain a Certificate of COnwnnoself-nsum fwwarker's Compere
muhm, at provided far by Section 3100 of the labor Code, far the performance of the
work for which this permit is issued.
❑ 1 ban and will maintain Worker's Compensation Insurance, as required by Section
3100 or the Labor Code, far the performance of Ne work for which this permit is issued.
My rke s m/pe tion Lnmratta s er Policy number ij q
COF P.XEMPr10N FAO
E KERS'
COMPENSATIONINSURA CLAV
O'bssecdon reed not le completed if the permh is Room hundred dollars ($100)
or less.
1 cenHy that In the perromunce of the work far which Nis Permit it issued, 1 shall am
employ any person in any summer m ss to become subject to the Workers' Compenudon
Laws of Calirwals, Date
Appham
NOTICE TO APPLICANT: If. after making this Certificate or Eacmption. you should
become subject an the Worker's Compensation provisions or the labor Code, you mum
r forthwith comply with such provisions or this permit shall h deemed mvokcd.
�i CONSTRUCTION LENDING AGENCY
Ihereby lending agency l'tar the Performance or
- �--
orwhicftmNatthemisaconsteesinn
Ric work for which this pennis is issued (Bata 7091. Civ. C.)
L
Addndeh
� Lender's Addmsi
1 certify that i have read this application and rule that are above inrmmmion is
'
correct. I agree to comply with all city and county oNinances and state laws missing to
building construction, and hereby amhorim mpresentatiws of this city to enter upon the
a arove.mendoneapnsperty for inspection porpores.
(We) agree to saw, indemnify and keep harmless the City of Cupertino against
q liebilitles,judgments. costs and expenses which may in any way accrue against said City
1 in 7 APPL cawoft
UNDERSTANDShis ANDCOMPLY W:Ty ALL NOWPOINT
Issued by: Date
SOURCE RGDLATIGN„
Re -roofs
Type of Roof
X -ale-
S' rc o(ApplicrmuContractor Data
rm a
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or tuture building uceupant store or handle haurdous mnerial
as de0ned by the, Cupertino Municipal Cade. Chapter 9.12. and the Health and Safely
Code, Settled 25532(a)1
❑Yea V.
All roofs shall be inspected prior to any roofing material being installed.
If a roof is installed without first obtaining an inspection, I agree to remove
Will the applicant or rulum building «euparal use equipment or devices which
alt hmardnua air conuminams Is defined by the Bay Area Air Quality Management
all new materials for. inspection.
DlmricO
Cl Yet; )Vo
.
I have mad the woardtws materials requirements under Chaplet 6.95 of the Califon
Iia ahla& Code. Seedom2591154 a tnil
Jc sunt thanCup
55 3aandomhility n
ar,roand
arca oat c fmn.1 haw a ectorrom, than It u dtify Ih eau of the
require iswhi- mas[ bemet priormisuanccofaCcrtific of Occupancy.
Signature Of Applicant Date
a
All roof coverings to be Class "B" or better
Owner orauthormcdagent pate
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P
e
FD r
T Ow"l.
fa i"6 �D
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IN
CITY OE
This Set bt 7.e s ;rr--
be kopt o
Vie' lob et ah limes and it is un
lawful tr , rake any changes or alterations
on same without W.iltecf Cupert on from
the building Dept- City
The eteMPrhC of this plan end specificabons
3NALL NOT be haid to palma or pr be ac
ppYeval of the violctten of any provisions
1 8\ i `to Ordihanct ST State Law.
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