07100126 CITY OF CUI'ERTINO �
BUILDINGDIV1S10N PERMIT V`-'���������������� '
,
PERMIT NQ.
BUIL r ��� ES �LENVIEW AV HUCK COrfST COMPANY 07100126 .
pERMTT LSSUE DATE
'.R'S NAME: .
�ATIBANDIA 695 S 1`�TH ST 10/17/2007
SANITARY NO. CONTROL NO.
PHONE: �4OH� Z9f >-2374
BUILDING PERMIT [NFO
ARCHITECT/ENGiNEER: HLDG ELECT PLUMB MECH
� 0 � �
� p � LICENSED CONTRACTOR'S DECLARAT[ON JOU DeSCCIptlOil
� v� 1 hcrcby aCfirm that I am liccnscd undcr provisions aCChaptcr 9(commencing REPAIR � 1 FT �F FOLTNDATI ON & PORCH SLAB
; z� with Scction 7o00) of Division 3 of thc Busincss and Prafcssions Cadc, and my liccnsc is
�= y in full foree and cffec�
� v� 2 Licensc Class Lic. N
p Datc Contrac�nr
: F' � ARCHIT6CI'S DECLARATION
j� . �
a 1 undcrs�and my pians shall bc uscd as public rccords
)yU
' a y Licensed Pn�fcssional
: � < OWNER-BUILDER DECLARATION
� a� I hcrc6y alTirm that 1 am excmpt Crom thc Convactor's Liccnsc Law far thc
p O (ollowing rcasoa. (Scc6on 7031.5, Business and Pro[cssions Codc: Any ciiy or county
�$� which rcquires a pertnit to conswct, allcr, improvc, dcmolish, or repair any sttuetucc
rior W i�s issuancc, also rcquircs �hc applicant for such permi� to filc a signcd statcmcn� Valuation
°_ Z; � ;;q. Ft. Floor Area $ 4 9 0 0
< �hat hc is liccnscd pursuant �o the provisions of �hc Contracux's Liccnse Law (Chaptcr 9
� F�(commencing wi�h Section 7000) of Division 3 of Itrc Business and Professions Ccde) or
i� r. that he is exempt Neicfrom and Ihe basis Cor the allcged exemption. Any violation at
Section 7031.5 by any applicant far a permit subjecu ihe applicant ta a civil penalty of 3 6 9110 3: 3� Number Oeeupaney Type
not moce than five hun dre d dollars (5500)• '
❑ I, as owncr oC ttrc pcoperty. or my employca with wages as the'v solc compensation,
will do thc wflrk. and �he suuctuY is not inte�dcd or offued for salc (Sec. 704:, Business Required Inspections
and Pro(essions Code: The Canuactor's License Law docs rmt apply ta an owner of
propeny who 6uilds or improves lhercon, and wha dces such work himsel[ or Ihcough his
own employccs: providcd tha� such improvements are not i�tended or offered Cor sala IC,
however, Uie building or impcovement is sold within one year oC complcdon. Ihe ownu-
builder wiil have the Mudan o[ proving t6at hc did not build or improvc [or pu�po.0 of
salc.).
❑ I, as owner of �he property, am wcciusively conuacung with licenud rnnuactors to
conswct tlx pmject (Sec. 7044. Business and RoCessions Code:) The Coatrdctors Li-
ccnse Law daes nol apply �o an ow�cr af propeny who builds or improves Ihneon. and .
who conuacts Cor such prajcc�s wiih a comractor(s) Iicenaed pursuant to Uu Contracmfs
License Law.
❑ i am ezempt under Sec. , B& P C for �his �casan
er Date _ . -
WORKER'S COMPENSATION DECLARATION
I 6ercby �rm under penalty o( perjury anc of the folbwing declaradons:
❑ f hsve and will maintain a CertiGcatc of Conscnt lo se!(-insure for Workcfs Compen-
sation, as provided for 6y Sectian 3700 of the Cabor Code, for the pedormance at the
woric for which U�is pertnit is issucd.
❑ 1 have and will maintain Worker's Compensation Insurance, as �equircd by Section .
3700 oC the Labar Code, for the pedormance of �he work far which this permit is issued.
My Worker's Compensadon lnsuranee carticr and Policy number are:
Cartier. Poliry No.:
CERTIFICATE OF EXEMPIiON FROM WORKERS' .
COMPENSATION INSURANCE
(This secdon necd not bc completed if the pertnit is for onc hundred dollaca (5100) .
nc Icss.)
I ceni[y ihxt in thc performancc af ihc work Cor which U�is pertnit is issucd, 1 shall not
e.^.�ploy any person in an m to ' ct to ihe Workcrs' Compensazion
Laws of Califo i a
Applicant
NOTICE TO PLICAM: [f, making this CcniGcate of Excmpuan, you stwuld
bccome sub' �o �hc Workcr's Compcnsation provisions af thc Lahor Cadc, you must
, O foMwi�h comply with such provisians or this pecmil shall bc dccmcd ccvokcd.
z � CONSfRUC1'ION LENDING AGENCY
(...� �-. I hcccby afTirtn U�at tAcre is a conswctinn Icnding agcncy Cor thc perfurmancc u(
p�,, � thc work fu� which ihis permit is issucd (Scc. 3097. Civ. CJ ,
W Q Lendcr's Namc
] z L,cnder's Address
I certify tha� 1 have rcad this application and siate that thc abovc informauun is
� O cortect. I agrce to comply with all ciry and counry orttinances and state laws rclating w
� U building conswction, and hc�cby authori�t rcprcscn�a�ivcs of �his city to cmcr u�n lhc
above-mentioned property for inspecuon puqwses.
� a (Wc) agree �o save, indcmnify and kecp harmless ihe Ci�y of Cupertino against
�� liabilitiu, judgmcnts, costs and expenses which may in any way accrue agains� said City
V z in consequence of �he granting of Ihis permit. DSLe
�+ APPLICA UNDERSTANDS AND W1LL COMPLY WITH ALL NON-POtM' Issued by: .
SO RCE ULA NS.
Re-roofs
i atu ofAppli tracto Da � Z' of F.00f
HAZARDOUS MATERIALS DISCLOSURE YP
Will ihe applicant or futurc building occupantstorc or handlc ha•rardous marcrial
^s dcfincd by thc Cupertino Municipal Codc. Chaptcr 9.12. and thc Hcalth and Sakty
dc, Scction 25532(a)? 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 ihc applicant or futurc building occupant usc cyuipment or cicvic.cc which
cmii hazardous air contaminan�c as dcfincd by thc Bay Arca Air Quality Managcmeni all new rt iaterials for inspection.
District?
❑ Ycs �Nu
I havc rcad the twardcws maicrials requircmcn�s undcr Chaptcr 6.95 of �hc Califor-
nia Hcalth & Sa(cry Codc, Scctions 25505, 25533 and 25534.1 undcrsund that iC �hc building
docs not cu ntly havc a �cnan6 �ha[ it is my respansibility to noufy Uic a:cupant of thc
rcy remc which s me�priorto' uan CaCcnifica�cofOccup �r. Signature ofApplicant 11 Date
All roof coverings to be Class "B or better
cr or authorizc agcnt �