05100107 CITY OF CUPERTINO *• + " ` h'`�'"`"'"` ''" " ` ` '"' -
BUILDING DIVISION PERMIT C)1'iTRAOR INFl1 rI01�
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BUILDING ADDRESS: s pINN BROTHERS CONSTRUCTIO SP,ERMITNO'05100107
R'S NAME: PERMIT LSUE DAM
BAY COLONY 75
PHONE: SANITARY N0. CONTROL N0.
408) 252-913
ARCHITECT/ENGINEER: BUILDING PERMIT INFO
BO EO PLO MEOCH
lop LICENSED CONTRACTOR'S DECLARATION Job Description
�+ I hereby sabot that 1 am licensed under provisions of Chapter 9(commencing
with Suedon 70M)of DivWon 3.fthe Buinevaed Pmfammms Code,and my license is
mfull tome andoffea Ia. NEW CONDO-1, 178
t 2 Liceua Class Lk.R
Daege� Contractor G
ARCH"ECTS DECLAIRATIO
i 1 understand my plans shall W used as public records
iyUp.
•G'7 Licensed Professional
OWNER-BUILDER DECLARATION
<F I heresy alum that 11. exampe from the Cantmou Co License c Law for the
following mason.permit
i 7 mum cutin.and Pm,de oll Code:My city Or county
i$ which rtpuisea a Pmmit re acres the alter,improve,hpurailo of repair any utomure
�12 2S27
•i y
that
m its issuance.F also dean to requires the appiianffor Cor ler'm filo Law(Rakmcm
G NatWkliecnxJnturmanuothentrovisiouofthe ConlncmciUterhmlaw(CMPer9 Sq.Ft. Floor Area Valuation
(commencing with Section 70DO)of Divirian 3 of the Business and Pwkshinu Code)or
that he is exempt therefrom and the bask for the alleged assumption.Any violation of
Section 7031.5 by any applicant for a permit subjects the applicant he s civil penalty of 0 0 Occupancy Type
not acme than rive hundred dollars(5500).
❑I,u owner of the pmpeny.car my employed"with wages u deir wk compemdon,
will do the work and lbentucture is notimended or offered formle(Sm.7044,Business Required Inspections
and Professional M
Cade:The Cantrtara Lim us Law dot's not apply 0 w Owner of 9 P
property who buildsorimprovra thereon,andwbO doeaauchwork hiceselfarNrouglt his
own employed",pmvlded that such Improvements are ret intended aroffmad formic.If.
however,to building or Improvement is mid within one year of completion,die owner-
builder will have the burden of proving Nal he did Oat Wild or improve for purpose of
vk,),
❑1,as an=of the Property,am exclusively convecting with Imumand cenuwron in
convect the project(sec.7014,Business and Pmfeniotu Code:)The Coaummr's U-
ced"e Law dam not apply m an Owner of property who build,or improws thesean,and
who contracts for such projects with aeonvemarts)licvtsed pursuant to the Contramml
Liceme Law.
❑lore sump,under See ,B A P C fm this ramO
Dae
WORKERS COMPENSATION DECLARATION
1 hereby slam under peully or perjury ore or the following decleredou:
bare and will maintain a Ce late of Cement to=11-insure for WorkcfsCmnpcn.
Lai
provided for by Section 3700 of the Labor Code,for the performance of the
wa r which this permit is issued.
1 have and will maintain Worker's Compeuation Insurance,u required by Section
37W of the labor Code,for the performance of the work for which this permit Is issued.
My War ampemaar to unnce artier and Polity 1
Caruar: W S Policy No:
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
Cfhu rection used not W completed]film permit is faron t hundred dallus($1001
car las)
I Comly,that In the performance of IW work for which this Permit Is Wum.I shall not
employ any petmn in my mmncr an as to become subject in the Warken'Cmnpcaadon
Laws of California.Data
Applicant
NOTICE TO APPUCANr:If.after making this Certificate of Exemption,you should
become subject to IW WorkeYs Compcaavan provisions of the Lobar Code.you most
.J z forthwith comply with inch provisions or this permit shall W domed masked.
zy CONSTRUCnON LENDING AGENCY
'rh 1hemby.farm char them Ica.construction lending apocy rat the performance of .
ai> the was fur which Nis permit Is issued(See.3097,Civ.C.)
c Lenders Name
a z Lander'SAddress
(�Q 1 certify that 1 haw mad this application and sum anal the above Information is
(L H correct 1 agree to comply with all city and county ordinances and state Itwf rotating m
QU building convection,and hereby sudwrim mprescnntives of this city to enter upon the
r gLl shout-memiuned property for inspection purposes.
G (We)agree to Saw,indemnify and keep harmless the City car Cupertino against
aF.t N limiliosof
w whmaymanymsysecmeagainslsaid City
woe t.D N LL COMPLY WITH ALL NON-POINT Issued by: Date tF,/7.a
I Re-roofs
signora arAppllcm Onlrector Date Type of Roof
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or ruuue Wilding occupant store orhandle basset material
d fined by the CuPedno Men
I Code.Chapter 9.13,and the Health and Sanely
.SeNoa25532(a)7 All roofs shall be inspected prior to any roofing material being installed.
❑Ya o
Will the applicant or future building oaupant use anointment or devices which If a roof is installed without first obtaining an inspection,I agree to remove
emit h mmmst All contsmiml u fined by the Bay Arca Air Quality Management all new materials for inspection.
District?
❑Ya u
taw mad he Wardousmatcrials vimmcnuundc,Chmcar6.95 orIW Cutter.
nisH SalclyC Smuorts 25505, 33 and 75534.1 understand the ifthe Wilding
dna t rely enactcharItis y responsibilitym,udl'ythenecupamor chc
ren rem WMOI pdarI gan"Of.CcdT a(Occupanry. Signature of Applicant Date
OwnerOnuthamad egcnt Date All roof coverings to be Class"B"or better