05060001 CITY OF CUPERTWO 77aqa $=:,rt:e 'mT7;Pb)AI*9t�, s -
BUILDING DIVISION PERMIT T :0 ,4 RACTOR INF, ItM G ON;.t<
BUILDING ADDRESS: PERMIT N0 5060001
99439 OAKCREST C1
ER'S NAME: PERMIT ISSUE DATE
ERAN COHEN 07/08/2005
PHONE: SANITARY NO. CONTROL NO.
ARCHITEC(ENGINEER: BUILDING PERMIT`INFO
BO EO PLQ MECH
O
30o LICENSED CONTRACTOR'S DECLARATION Job Description
i� 1 hereby arrant Net I w licensed under provision of Chapter 9(commencing
IN Section 7")of Division 3 of the Business mad Professions Cade,and my Eaton is inmBfaroeandaffect. ADDITION 453 ' 1ST & 2ND FLOOR
_ Licenm Clw Lk.P
II-F
Data Contractor BEDROOM/BATHROOM/ENTRYWAY/BALCONY
e ARCHOECPS DECLARATION
y 1 understand my plw klull W used as public records
J F
a o
Licensed Rafessiond
...7777 Oat I am exempt
from
DECLARATION
$ I berchy.(ileo Net 1 1, exempt from the Contras Co License Law for the
ON following . (Section Icon L4 Business and Improve.
demes Code:Any city or county
'$ whichitsissacquires r permit re enuswcL plus nt for
h Permit t ur repair any stmcmm -
_ZL' pdorbiu iuued pursamquime the.pions Of far Cutneou's Ole trig.(Raumhnl
<
that beuliceoithSectionT theM)ofiioaofthe attheBmincemaJmaelaw(Codur9 Sq.Ft. Floor Area VaI1.t�igGul39
SL s (eommcs exempth Section and ofbasisDivision 3 of 0 B ed exam ton.my vie Code)of
'��—
that be V exempt Nemfrom and Uu basis for the JR�gW exemption.My Wolation of
Sec0on.701d by any applicant for a permit subjects dm applicant to a civil penalty of APN Number Occur Type
not more one nve hundred dollars(SSW). Occupancy YP
❑1,an owner of the property,or my employees with wages as their sole compensation, 34248011 . 00
wilislo the work.and ft suracture is not intended ormflered Imsl.(Sm.7044.Business Required actions
and Professions Code The Conu cures License Law Law donot apply se an owner of q p
property who bus Ida orim prow thereon,and who does such work himself orthrough his
howemPloyw,ping or improvement mehlmPmvem white myouMedmaffered for Owner. [.,��t'k�,�� 6t ��
man employees.
provided
uchimprovermussmno Year ber!co letim.the tkh'lfL'w (pY]7��f�t )�tgtfm
builder will haw the burden of proving that be did rot build or Improve for purpose or
ale.).
❑1,as Owner of the property,am exclusively contracting with licensed conmactors an ��� /
caulmo Business project(Sec.7044.Businand Profession Cade:)The Commoner's Li. 2006
curse Law does not apply w a owner of property who builds or Imp rvn thnmon.and, a L U
who contracts for such projects with acamnscmds)licensed pursuant an the Cams mmes
nm law.
Iemesemptunakerse.,(��`'.�-T+�^� ,B&PCfor ,scan �(FJ�=�y'� rg�, `la
r ER'g COMPENSATION DECLARATION
q 4 /I,�rD�� ` ,S
I hereby affirm under penalty of perjury am of the following dedr adaa: _ TJ
❑1 haw and will maintain a Cerdfiam ofComra to self-iaum far Worker'aCompen-
aatian,u proHded for by Sextan 37W of the labor Code.for tiro performance of an
work for which this Permit is issues.
❑1 have and will maintain Worker's Compensation Insurance.as required by Section
37W of the labor Code,for the performance of the work for which this pennon;Issund.
My Worker's Compensation Insurance cartier and Policy number are:
Cartier. Policy No.:
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(This cNm used nothecompleud Eche permit is return hundred dollars($100)
or leu)
1 ardfy that In the performance of the work for which this permit Is Issued,I shell not
employ any person in any m m1rm b omembjecuo the Workers Compensation
Laws of California.Dau
Appllant
NOTICE TO APPLICANT:If.after making this eminate of Exemption,you should
become subject to the,Worker's Compensation provisions of the Laiaw Code,you most
rQz forthwith comply with such provisions Nis permit Nall he shamed rooked.
Q
E ti COft.is sT10NLENDING AGENCY
'r—� k for which this
Net Nem BacouWcl 3W,Cing agenry l'nr Ne perfomtanm of
!Yi Le wish for which NIs posit d?used(Sec.3097,Civ.C.)
0 Lender's Name
z
Lender's Add. -
C)Q 1 certify that I have and this application and sun Nu the above information is
Ty cmmtt 1•gree to comply with all city and county ordinanttund state Ire reading to
Q U Wildingconswction,andherebyauthodmmprnentativesofNiscitytoenteruponft ,
L17 above-mart umd propeny for inspection purposes.
gL (We)agree to ave,indemnify and keep hvmlas an City of Cupertino against
V!Iiabllitics jadgmenu,asts sadexpeves which may in any way acarue agalauud City
ln conuence Of the Setall Of this rmit.
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT Issued by: Dated (�
SOURCEREGUL� 71,r f
Re-roofs
Signature of Appliant Contrecmur Da
HAZARDOUS MATERIALS DISCLOSURE Type of Roof
Will tiro applicant or future building accupat sem or handle hanrdous material
denned by the Cupertino Municipal Code Chapter 9.11.and the Health and safely
Section 15531()7 All roofs shall be inspected prior to any roofing material being installed.
t ❑Yrs 06.
Will the applicant or future Wilding occupant use equipment Or devices which If a roof is installed without first obtaining an inspection,I agree to remove
-unit haardoua air contaminants u dcfual by Na Bay Arca Air Quality Management all new materials for inspection.
District?
❑Yesf u
I have mad the haardausmaterials tequimmenu under Chapter 6.95 oftheCalifor-
nta Health a safmycadn.SrNoserVIM,25533 star 255M.i undemad thatifde Wilding
docs not currently hew a tens,Ns it 4 my mwreatility to mdfy Nc occupant of dor
requirements which mus be met prior to issuance ofa Oadfleme of Ocap%AID/ Signature of Applicant Date
Owner orautho .cd agent 7 Data All roof coverings to be Class "B"or better