08060145CITY OF CUP ERTINO°•«+
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IURMATION
BUILDING DIVISION PERMIT-C�1TI2ACTUR
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TBD - TO BE DETERMINED
PERMR NO.
08060145
E:
T ISSUE DATE
MARIE MERKHOFER
(ARCH=�GtNEER:
07/16/2008
SANITARY NO. CONTROL NO.
BUILDING PERMTTINFO
BLDG EIRCT PLUMB MECH
0 0 0 0
LICENSED CONTRACTOR'S DECLARATION
Chapter 9
Job Description
1 bereby affirm than I am founded under pmviuom or (commencing
wills Section 7") uroiviuon lords Business and Pmrcneinm Code. and my license is
ADD (120SQ) TO KTCHN, RMDL KTCHN(196SQ)& INCLDS
in full face and effect.
License Clea, Iic.g
STRUCTRL
Dao Contrecter
ARCHITECTS DECLARATION
1 u ecisand my plans Nall a used in public moods
Licenmd Pmfessirnal
OWNER -BUILDER DECLARATION
...
I hereby aRsm that 1 am exempt from the Contractor's license Law for the
fallowing resume. (Swum 7031.5, Business and ROfessiom Code: Any city or county
which requires a Permit m construct, alar, improv, dcmrllsh, m repair any swcture
prior o its issuance. also requirel the applicant for such permit to file a signed summcnt
rutWeislicensed of the Contractor', Lice. Law (Chapw9
Sq. Ft. Floor Area
Valuation
punuantmfpmvism.
d-
(commencing with Swoon 700M of Division 3 of the Busians and Rofesuons Code)or
$130000
that ate s exempt therermm and IM basis for the alleged emmpdon. My violation or
3 4 215 0 5 5 Number
Occupancy Type
ScWan 7031.5 by a" applicant fa a Ferrol, the app[icanun a civil Formby of
rot mem than fivs hundred drllas (SSW).
.
❑ 1. u awmr of see prpmry. m mY aoplOym with ultra as Ne'vmk cmnPewtkn,
Required Inspections
(Sin. 70th.
will dothewoks anee:
he ComsnolsmWedelORereoforn[ owner o•
Code: The cn License Law doer no apply lf rt owner
and Pmrwho
_
theemra
his
wlmbuildsorinspaves Ne in, andwoo aressuintwok himselfor is
W
for
own cro that such impmwmmtaare sea intended coffered for aleer,
ownemplayw,ding
towner. thebuilding r i year mmpkufor the Owe
uimpmwrmntamidwithinot
w of
will haw the burden of proving that k did not suW or improv for purpose of
ask.).
sab).
❑ 1, as mina of the property. am exclusively ce u acting with licensed contraction m
consuun the proem (See. 70sa. Business and Professions Code:) Th Cmmcmr's U.
.
ewe law dee not apply o an owner of property wan builds or impmrns thereon. and
who contracts for such gojecu with a canmmor(s) licensed pursuant m the Contractor's
License Law. A
X
01 e pt under�e . B d-P'yC In,,ded.
?//6W
Dae W
WORKER'S
WORKERS 'MPFIISATION DECLARATION
I hemby artrm umkr pwlly of perjury oro of the follwing declaodorme
❑Ilas+"aMw01maintaina GadrxaoofC=ntwself--in,umfmwm SCompan-
sauon, n provided for by Section PW of Ne labor Code. for Ne Perfommanm of are
wodt for which this permit is Trued.
❑ 1 haw and will maintain Workers Compertauon Inswanee, as required by Secure
,
37W of the lata Code, for the ncdormance efthe work fowbicb Nis permit is issued.
'
My Wmkers Compensation lwrasue carrier and Policy number are:
Cartier. Policy No.:
CERTIFICATE OF EXEMPTION FROM WORKERS
COMPENSATION INSURANCE
Thkxction ncW mmtbecomplemJ if im permit is formic toothed debars ($100)
or kis)
1 "Itifv that in the performance of the wok for which this permit s issued, l shall nm
empl%any Persm I..Ymammrs in e� asutl othewrrkms'Compensauon
laws of Caliroris. DamQ_L(a
Applicant
NOTICE TO APPLICANT: If. afar making Ns Cen eras or Emmplum, you snout!
become subject o fl�WorkeM1 Compensation provisions of Ne lata Code, you muse
comP1Y with such pmWiw m this permit shall W armed rewked.
CONSTRUCTION LENDING AGENCY
h uebl aiBrm that there is. emavucunn k sling agemy for dre performanw of
the wart for which this Permit Is Wood (Sce.3(191, Civ. C.)
Len lets Name
Lenders Addcas
1 comfy Nat 1 but. onto this application and sins ma the abow information Is
comeet I agate to .Ply with all city and only unit v and ass laws relating to
Wilding comatucuom and bcmby autherier mprexntauves of Ns city in cew upon the
ahnw-menudgm Property for inspection
npuryhms
(We) agme to aw, indemnify and keep hamlet iso City of Cupertino against
espim
emuand eapenseawhich may in any way amore .I., said Cly
Iiabilidcsucnc
in comcqumm or sM granting mums pvmiL
of
APP ICANT UNDERSTAN S D ILL COMPLY WITH ALL NON -POINT
S UR REGU T10N5.
Issued by: Date % `^•G�
Re -roofs
i m'nwre of Appbcamrconwc r ' ' Date
HAZARDOUS MATERIALS DISCLOSURE
Type of Roof
Will the applicant orrumor building oavpanl roc m Nndk hamaous teavA&I
a defined by do Cupertino Municipal Cade, Chapter 9.13, and the Health and Safety
. Section 25532(a)7
❑Yrs eNa
All roofs shall be inspected prior to any roofing material being installed.
Will the applicant or future Wilding occopanl uw equipment Or dcvions which
If a roof is installed without first obtaining an inspection, I agree to remove
eemii ce mous air contaminants a cicrined by the Bay Area Air Quality Mragemcni
all new materials for inspection.
❑Yrs Ef No
I bode mad the Mvardmwsmateriasrequiremcnsumkr Chapterg.95 or Ne Calif.,
-
niaHcalNk Safety CoM.Secuom23N3, 25533pd 25530.1 understand Naifthe building
dors rot omendy haw it anan ft s mynaspomikliry o noufY the oroof do
rtgnimmems wrath mm ar. cuorm,te ar
Signature of Applicant Date
/G/0 X
All roof cover n s to be Class'jj"
g or better
owner or aathrripea ager '
Date