06020165 CITY OF CUPERTINO � ' '°* -- "t % "'''� •�
Bml.mrvc Drvlslofq PIrRMIT ,CONTRACTOR11 ,,; ORMAI,
JON
BUILDING ADDRESS: PERMIT N0.
22581 ROCARDP RD
ER'S NAME: PERMIT ISSUE DATE
JENNIFER LU 10413 TORRE AVE . 03/22/2006
PHONE: SANITARY NO. CONTROL NO.
(408) 781-7620
ARCHITECT/ENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
(� 0
+Its, E LICENSED CONTRACTOR'S DECLARATION IobDescri tion
U 1 hereby affirm that I am lice std under provisions of chapter 9(commencing P
with Section 70mpof Division 3ofdm Business and Profession,Cock,md try he...is in full force and effect. INTER. REMODEL/MINOR STRUCT.
qz L;an c ue.x� 1O 23 6 TURN 2 BED & 1 BATH TO MS SUITE
�t• Da¢ ���i Contracmr A/✓n,%-1 c//i.,i/i
ARCHfTEC1'S DECLARATION
is V 1 understand my plans shall be used as public records
wt; Licensed Professional
OWNER-BUILDER DECLARATION
sF 1 hereby affirm that I am exempt from Ne Contrxcrar's License Law for Oe
00 (allowing reason.(Sceuun 7(131.5.Business and Professions Code:Any city at county
<S ff which requires a Permit to construct,alcor,improve,demolish,or repair any structure
o;i prior In its issuance.also requires the applicant for such permiuo File a signed statement
fsothat heislicensed pursuant oheprovisions ofthe Contractor's License Law(Chapter 9 Sq.Ft. Floor Area Valu
a~$ (commencing with Section 7000)of Division 3 of Ne Business and Professions Code)or
Q that he is tempt therefrao and the pedis for the alleged eumption.Any viola don of
Section 7031.5 by any applicant fan permit subjects the applicant to a civil Penalty of3 � ��e�0 0 Occupancy Type
not ream than five handrail dollar 3500
0 L as owner of the pmpeny,or my employees with wages as their sok compensation,
will do the work end theswcture isnot intended or offered for sale(See.70ss,Business
and Professions Cade:The Canuacmr,License Law does not apply W an owner of Required Inspections
property who builds m in,proves thereon,a cad who does such work himself or through his
and employes,provided thmauch improvements art not intended uroRered forst le.If,
however,the building or improvement is sold within one year of completion,the owner.
builder will baste the burden of proving that he did not Wild or improve for purpose of
sale.).
❑1,as owom of the progeny,am exclusively contracting with licensed contractors to
construct the project(Sec.7044.Business and Professions Code:)The Conumun's V-
whocLawdosenotapplywanownerofpropertywe Wildsoriho in th thmarac and.
who comncu for in ap projects wine commcror(s)licensed pursuant ro the Contractor's
0 Law.
Iam on,exempt under Sec. ,B&P C for this ManorDate
WORKERS COMPENSATION DECLARATION 1
1 hereby affirm under Penalty of perjury one of the following dxlantions: /Z�
❑Mesas and will for byn a Cion 37 W of she Labor
Cook,for tforerfrkeh ce of the
`
work f r pro h this for by Section 3]00 of she IaWr Code,for the Performance a(the 1/J�
01 for which ill permit is issued. /
❑1 have and will maintain Wurkcr's aram of tare w huurantt,h required by Sss ud.
3]00 of the labor Code,for the performance of the work for which this permit is issued.
My Worker's Compensation Insurance artier and Polity number tic:
Cartier. 5/a)� �O�Pol;N No.: WORK S'9I
CERTIFlG OF EXFMPIION FROM WORKERS' ffF---��a
COMPENSATION INSURANCE I
(This auction need not tan mi
completed if the pert is for one hundred dollara(S IM) / / ;o
car ices)
I unify that in Ne performance of he work for which this Permit is issued,)shall not
employ any person in my mmncran as W become subject to the Waikent Compensation
Laws of Califomia.Data
Applicant
NOTICE TO APPLICANT:If,after making his Ceni0cale of Exemption,you should
become subJect W use Warkcr'3 Compensation provisions of the Labor Code,you must
.,O faMmm
wlth comply with such provision or this Permit shall be deeed arked.
Zy CONSTRUCTION LENDING AGENCY
[-a I hereby affirm Nn than,iso conevuctino lendingagenry InnW peohmminttuf --
fl>
be work for which ria permit Is issued(Sec.3097.Co.C.)
W lenders Name
z Lender's Address
V Q 1 certify that 1 basso read this application and sure that nc aWve information u
WF correct.I agree to comply with all city and county oNinances and staW laws relating to
OU building construction.and hereby authorim representatives of this city to enter upon the
a bon-mmllllned Property,for Ins,ehim purlgYs.
H y (We)agree to save indemnify and keep harmless the City of Cupertino against
fn liabilities,judgments.casts and expemas which may in my way accrue against said City
V z in consequence of the granting of this ITTOIL
^ APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT Issued by: Date
SOURCE REGULATIONS.
/ Re-roofs
Stgnmure of WanuContmcmr 'Dire
HAZARDOUS MATERIALS DISCLOSURE Type of Roof
Will nc applimt or futum building accupmt score or handle hvardous nam rial
as defined by the Cupenina Municipal Code,Chapter 9.11.and the Health and Safety
c.
Section 13532(a)?
❑Ye, All roofs shall be inspected prior to any roofing material being installed.
Will the a licant or future building aces am ese If a roof is installed without first obtainingan inspection,I agree to remove
pP g e cyuipr Qu or Mara which
corm hazardous tie contaminants as defined by the Bay Area Air Quality Managcmcnt all new materials for inspection.
Disuial
❑Yes
1 have read the ha ncrimismaWrials re pikemen undcrCWpter(S95 of the Califor-
niaHeal"SidCLYCOdu,Sceuwu 25505.15533 and 15531.1 understand that ifte Wilding
docs on currently bare it enam,oat it u my rcvpoo,bili y W notify the occupant of the
requirements which must be ren prior In issuance of a Ccnificae of Pancy. Signature of Applicant ' Date
-� 3z/o
Owner oranthanmdage¢ Date All roof coverings to be Class "B"or better