04030051o
Y OF CUPERTINO
�' F u �^`�^""' x
UILDING DIVISION PERMIT.CONTRACTOR
R
INFORMATION'
L111111DINGADDRESS:
142 DRNT�;QN PIT
PERMIT NO04030051
'S NAME:
PERMIT ISSUE DATE
ONE:
SANITARYO. 1/08,12 C NTROL NO.
ARCHITECT/ENGINEER:
BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
0 � 0
LICENSED CONTRACTOR'S DECLARATION
I areby affirm Thal 1 sm licensed under pmviumu of Chapter 9 (mmmcncin6
l Job DesCl[ pr
p
with Sceemot 7")of Division] or the Business and Prefessims, Code. and my license is
a� III�YC�I
LEE
uc...0 Lt..N
ADD 364 SQ.FT. & UPGRADE
rotiLfreer.
Dan-ContractorAUG
4 2004
ARCHITECTS DECLARATION
1 undcnand my plans mall W used m public records
� IIID
BUILDING
Licensed Professional
OWNER -BUILDER DECLARATION
tib 1�t G
1 hereby .(Tion that I exempt from the Contnnofs Law Tar the
Any
:
Cute: Any Lit,
I c county
703IS.Business and Pm.
following or..
are s
Ire dcona anytatement
CfapCmsl su.h
pennit t Cores
for suchpermitm Nese Law statement
re the for permit to a sig
poornitsissuance,a(mdnequirts the
poor itsi
Ft. Floor Area
Valuation
in., he islicensedwit Pusaam previsions ccnseaw(Chaplm9
Oahe
da,")
Sq.
7to Buanessan
of Diviovnf
(commencingwith and ProfessionsCbe) or
or Division) ofthecZcd
axe
that a u exempt tartfmm and to bazu for the Jicgctl exemption. Any violation of
mfm]and
3MUOMING00
Occupancy Type
Scedon 7031.3 by any applicant for a permit subjects the applicant to a civil penally of
not mon Nan Bw hundred dollars (SS()[)).
0 1, as owner of the pmNny, or my employees with wages as IAV sale compensation,
Required Inspections
will do the wort end on, stmcrose isnot invaded or Offered im age(Sec.7W. Bud.
and Professions Cade: The Cannot Littve Law does not apply to an Owner or
pmpeny who builds or impmws thereon, and whodoes such warkhimself orthrough his
own employees, provided that such improvements an, not intended oro@nW penile, It,
however. the building or improvement is sold within am tsar of completion, the owner.
builder will have the burden of proving that a die not build or improw fur purpose of
ak .
I, as Owner of the property, am exclusively contracting with licensed contractors to
bovtruct rat pmjcct (See. 7040, Business and Professions Cade:) The Conuecbts Li-
_
cave Law does not apply in an owner of property who builds or impmws thereon, and
who concocts for such projects with a eonlnnor(s) licensed pursuant to the Contractor's
License Law.
❑lam exempt(See. .B&P C for this reason
ORKE COMP NSAT �ION//%%
1 hereby affirm under pevlty� arc of to foileymryaQ onstions:
I how and will maintain A CONfcale of Conant to self -insure far WorkersCompen-
atian, u provided fm by Section 3700 of the labor Code, far to Pcrfomnna of the
work Tor which this Permit is headed.
0 1 have and will maintain Worker's Compensation Imum m, a required by Section
37M of the Labor Code. for the performance of the work for which this permit is issued.
My Wormer Compensation Inwnnce carrier and Policy number am:
Cartier. Policy No.:
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(This action need not he completed if t e Permit is for one hundred dollars ($100)
or less.)
1 comfy Nat in the pc,fotramea of the work for which this permit or issued. 1 shall or
employ any penson in any manner a as to hammc aubjecuo the Workers Compensation
Laws of California. Data
Applicant
NOTICE TO APPLICANT: IL after making this Certificate of Exemption, you should
become subjoin m the Worker's Compensation previsions of the labor Code, you mus
forthwith comply with such provisions or this permit spall W domed revoked.
CONSTRUCTION LENDING AGENCY
1 hcrtby affirm that then its construction 3 n gency, for the Performance of
' to work for which Ores Derrell u issued (Stt. ]119], Co,Civ. C.)
7.
landcrs Name
landcr's Aeemss
j 1 certify Nu I have read this application and one this the abw information is
' correct, 1 agree to comply with JI city and county ordinances and suite laws mlating to
building construction, and hereby authorise repoesenottoCs Of this city to enter upon the
i abow-mendo^ed pmpeny for inspection purpose t
(We) agree to arcmharmless , indemnify and keep the City of Cuppano agJvt
j liabilities,judgments, costs and expenses which may in any way aeLme against aid City
in consequence of the granting of this Permit.
' APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON -POINT
Issued by: Date
SOURCE REG ATIONS.
Re -roofs
Type of Roof
S' nevem ofd li anU n
Ro,.. MATERIALS DISCLOSURE
Will the or future billing store or ardlc ety
vd
a Cupertino e. Chapter Health
Om Cupertino Muninpel Code. Chapter 9.11. and the HLaIN and Safety
az dp.See Safety
Section
e. Seafn zssynan -
Yes KNo
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 the. scant or future building occupant tome t or devices which
PP 6 p a Air Quality
is hvardous air emotions is Defined by the Bay Area Air Quality Managcmcnl
all new materials For inspection.
isvicl?
0Vv Nd
In maJ Ne haaaNuus materials requirements under ChaPvr6.95 of the Califor-
niaHealth&noulyyCalc.Soom.omit
myranens5J0.1 to roof to acucbuilding
doe trot cu�nlly haw a mnanL Nal it u my remponsihilitY to retifY the occupant of Ne
requiremonts which mu9v6orto ire anae ora Cent Oce Occupancy.
Signature of Applicant Date
All roof coverings to be Class "Bt' or better
Ownd,or.uthonoxxiage Dam