05100005 E2445
TY OF CUPERTINO nr� �` � '-
BUILDING DIVISION PERMIT rCONTRAC`�TOR�INFORMATION i':
DING ADDRESS: SAMUEL CONSTRUCTION PERMIT NO.05100005
ER'S NAME: PERMIT ISSUE DATE
SUNNYVIEW LUTHEREN HOME 17 192141
ONE: SANITARY NO. CONTROL NO.
(408) 249-2828
ARCHITECT/ENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
0 0 0 0
�Oo LICENSED CONTRACTOR'S DECLARATION Job Description
O F I hereby affirm that I am licensed under provisions of Chapter 9(commencing
� u wiNScedon70(111)uf Division Sof NC Busincaand Profcssiom Codc.md in,liemuC is
mmu tome and erfecc � 5044J]�— REVISION--ADD POWDER ROOM
e rte Liecnsc Class Lic.p
o-c Dole /t/4/25_ Can
lreewr w w trial)
ARCHITECTS DECLARATION
¢ I undersand my plans shall he used u public records
>au
s u.I Licensed professional
`Og OWNER-BUILDER DECLARATION
I hereby.'firm N
at I am exempt from be Contractor's License Law for the
00
-O O which
.Iowa arch n]In 1.3.Business and sae.d1rludi h.or Any city esameacounty
<m to which myuimx n permit re cnnarua plan improve,de Permit
t fie pair any xlrvcmm 0
n
to Prior(it its issuance,also requires the applicant for such permiuofilc aligned smmmem
-i< that he is licensed pursuau
no the provisions of the Contractor's License Law Comm,9 Sq.FL Floor Area Valuation
iI-$ (commencing with Section 70(10)of Division 3 of Me Business and Profession Codd)Or s
Q -
that he is exempt Mcmfrom and the basis for the alleged exemption.Any violation of
Section 7031.5 by any applicant for a permit subjects de applicant 10 a civil penally of r 0 Occupancy Type
not mart Nan fin hundred dollars(SSW).
1,as owner of the pmpeny,or my employees with wages is their sole compensation,
will do Me wort and be structure is notinerWed or offered for sale(Sec.70th,Business
and Psofeadmu Code:The Contractors License law does trot apply to an owner of Required Inspections
property who builds orimpmves thereon,and who doesauch work himself or brought his
Own employees,providcd that such improvements arc not intended or offered for sale.If.
however,Ne building or impmvcment is Card within one yea of completion.Ne Counter.
builder will have Ne burden of proving Mat he did not build or improve for purpose of
sale.).
❑h as owner of the property,am exclusively contracting with licensed Comnct as to
C005hoct Ne Project(See 70,14,Business and Pmfosions Cotler)The Contractor's Li.
cense Law docs net apply to in owner of property who Wilds or Improaex b rcon,and 0 -
who contracts for such pmjeca with a eontramm(s)licemed pursuant to the Contractors
License Law.
❑I am exempt under Sec. .B k P C for Nis reason "'<v,
f Data V
WORKER'S COMPENSATION DECLARATION
1 hereby Non under penalty of perjury ons of Ne following declarations: J
I haw and will maintain a Ceftificam of Consent to self-insure for Worker's Compere
satien,as provided for by Section 3700 of the labor Code,for Ne performance of the
work for which this permit is issued.
❑1 have and will maintain Worker's Composition Insuranm,ss eyuired by Section
3700 of the labor Code,for Ne performance of Ne work for which this permit is issued.
My Workers Compensation Insurance carrier and Policy number am:
Cartier. ">{�"I-G 'r c�Ul Policy No.: 2k57'T/7 L
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
othixsectinn need not becompleted if the permit is far one hundred dollars(SIM)
,it less.)
I cenifv that in the performance of Ne work far which bis permit is issued.I shall mol
employ any person in any manner an as an became subject to the Workers'Compensation
Laws or California.Dale
Applicant
NOTICE TO APPLICANT:If,after making this Certificate of Exemption,you should
Income subject to the Worker'a Compensation previsions of Ne Labor Coda,you must
z roMwith Comply with such provisions in Nis permit shall be deemed revoked.
zCONSTRUCTION LENDING AGENCY
'r. I hereby affirm that Nero is a coronation lending agency for the perfurom me of
x Ne work fur which Mia porrnit is issued(Sec.3097,Civ C.)
W A Lender's Name
6. Looder's Address
Z
U Q 1 certify Nu I have mad this application and state but Ne above information is
Ly F-' Correa 1 agree to comply with all city and county ordinances and stale laws relating to
0U building consuuclien.and hereby monodic representatives of this Oily to enter upon the
r W above-men Toned property for inspection purposes
(We)agree to save,indemnify and keep harmless the City of Cupminm against
f^' f4q liabilities,judgments,casts and eaperems which may in any way accrue against said City
U Z in consequence of Ne granting of this permit.
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT Issued by: Date
SOURCE REGULATION;; _
.L io�3foS - Re-roofs
Signamrc of Applicmect outs( Dam
HAZARDOUS MATERIALS DISCLOSURE Type of Roof
Will Me applicant or future building Occupant store or handle hanrdous motorial
u defined by Ne Cupertino Municipal Code.Chapter 9.13.and the Health and Safety
Alfte,Scctiex zss72(a7 , All roofs shall be inspected prior to any roofing material being installed.
❑Pea @R
Will the applicant or future building ocrupanl sex cytop hal or devices which If a roof is installed without first obtaining an inspection,I agree to remove
Fit ha/ardous air contaminants as defined by Ne Bay Area Air Quality Management all new materials for inspection.
Disaicl7
❑Yes
I have read Ne havmdous materials requirements under Chapter 6.95 CrNc Califon
nia Health&Safety Code,Sccdmcs 25505.25533 and 35534.1 understand Na if the building
dors not currently hale a tenant that it is my responsibility m notify the acupant or Ne
retiOncommn which must he met poor to issuaaccc Of a Centficate Of Occupancy.
Signature Of Applicant Date
5 /o a-y All roof coverings to be Class "B" or better
Owner or authorircd ag—enl Doc