04030156 CITY OF CUPERTINO
BUILDING DIVISION PERMIT 6ca, ORI
BUILDING ADDRESS: PERMIT NO.
04030156
2222q (-lTPP.RTTNTr) RM
OWNER'S NAME: PERINDISSUBDATE
E:KEDELL MTCRAFT, IN ANn TRARRA )A A SANTIARY 2.3 NOL NO.
ARCH17ECTIENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
il 8 Z, LICENSED CONTRACTORS DECLARATION
I hereby grim dut,I sam II creed under Provisions of Chapter 9(commoculng Job Description
witirSoctiam 7000)ofDivWon 3 of Ne Business and ftlessionat Code.and my license is
iEn aul-focraiesasdefer
ADP 803 SQ. FT. (GARAGE)
z Datea -Lc.s
C(attoa7mr
ARCHITECTS DECLARATION
I understand my pins shall W used as public mcmd,
Licensed Professianal OWNFR-BUILDER DECLARATION
I hereby afforn that I son exempt from the Contrector's License Law for im,
following neon.(Sudan 703 I.S.Business and Proficamm.Code:Any city.1 County
which requires a permit in=met,that.improm.denholish.or mpair any structure U
prior so Its issuance,also impure,ft applicant for such permit m fit.signed JR&Wnumt 629
Natheislimnwdp=antioftpmviionsoftkContmweLimnwUw(Chapwg Sq.TVFloor jeV � I Valu IOTI
ammencinswithSadon7ODG)ofDivition3offtSudnu,..dftf.d..C(ik)m it
Nat M Is exempt therefore,and the Wall for the alleged exemption.Any violation of
Section 7031.5 by any applicant for a permit subjects the APPlIcleft to a civil Penalty Of 3M]19?bIPbcF00 Occupancy Type
net duard that five hundred dollars($500).
0 1,n Owner of Ne property,a my cmidoymes with wage as their sole caropenseflon,
will do the work and thamuccume It Out intended croffered farmll.(Sc.7044.Butheasit
and Profession Code:The Cormemaces,License law does not apply se an Owner of Required Inspections
property who builds orimprotest thercon,and who doeslochwart lumuself orthraugh his
marcreplones,provided dui such improvements are notiffiscalked mortared forsale.It.
however.the building or improvement is said within am year of completion,deb owner.
budder will have ft burden or proving that W did not Wild or Improve far purpose of
1,as Owner of she property,am exclusively contracting with licensed contractors in
construct the pmjcct(Sec.7044.Business and Professions Code)The Contractors U-
"m Law does not apply in an owner of property who Wild,or Improves themon.and,
.he cenummus for much projects with a corchatur(s)licensed inusunt in the Commutes
License Law.
0 Ilares.V u B At P C for thismeasov
a 5t Data
ll PE ION�I
�ORKEXS CD NSADON OBIZI-ARATION
40 1 Whary.111. r penalty of perjury can of the following declarations,
F,have and will maintain a ocnificam of Comm to self-loscom fa Worker,Compen.
action,as provided for by Session 3700 of the Labor Code.far the performance of the
mark far which this permit I,issued.
0 1 ban and will maintain Worker's Compensation lommunce,as required by Section
3700 of the LdWr Calc,for the psolmermee of the work for which thus permit I.Issued.
My Workers Compensation Instance carries and Policy numb"am:
Carrier. Policy No,
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
n7h0 section need roftcompleted lithe permit It foranc handradollms;(SIM)
or M)
I certify that in the performance of the work for which this permit is issued,I shell not
employ anypcomn In my manners as to become subject in the Wort mes'Cooptutsmon
Lowe of California.Data
Applicant
NOTICE TO APPLICANT.Ir.after making this Certificate of Exemption,you should
became subject in the Worker's Commutation provisions of she Utter Code,you mum
z forthwith comply with such provisions or Nis permit shall W deemed revoked.
0
CONSTRUCTION LENDING AGENCY
1 hereby"ro dum ft.I.aconstruction lending agency for ft Performance of
> ft work for which this Knit Is issued(Sec.3097,Ch,Q
QLedees Name
Z)
0.z Lenders Address
U 0 1 cemly that I ban head this application and mass that the above information Is
correct.I agree in comply with all city ad county ordinances and sun lam meting to
U building construction,and hereby mulbomme mpressaistivas of this city to enter upon ft
albove-mentioned property for Impaction,purposes
(We)agree to save,indemnify and keep terminal the Chy Of CUPCni"O Against
iabil as.u maut.con,and expenses which may in my my accom agalmosmal City
n commiumn a of the granting of this Fermi.
r'iPPLIC I A UNDEBSTANDS AND WILL COMPLY WITH LNON-POINT 4suedby:3 �60 Date Y/ /
ULA ONS. R
PURCE
, Re-roofs
gnmum of AppitcanuContraccor Data
HAZARDOUS MATERIALS DISCLOSURE Type of Roof
Will the applicant or future Wilding ocamm,mom or handle hascurclaus material
as defined by the Cupertino Municipal Code,Chapter 9.12,and the Health and Safety
Code,Section25532(O? All roofs shall be inspected prior to any roofing material being installed.
0yes ten,
Will the applicant or future building Occupant=cquipmal or devi.as which If a roof is installed without first obtaining an inspection,I agree to remove
it humd'out air contaminants at darned by the Day Area Air Quality Management all new materials for inspection.
District?
Oyu )(No
lhave rod the humnicumols requirementsrmerrequirements underCluipter 6,95oftim Calder.
rise H.INaSafelyCodD,S=lomZ5505,25533ud25534,lun&nwdLhairthe tadidsh,
not c rely he..lamot,that it is My halaxOnsibilily 0 mail,she OeX.P.11 Of use
c c f C rull te f OC of Applicant Date
w Signature
,7 me a a ca 0 �
Owner or iunhorind,agent All roof coverings to be Class "B"or better