05080152CITY OF CUPERTINOae+�+'
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BUILDING DIVISION PERMIT
CONTRA.CTOR INF,OIiMArION:
BUILDING ADDRESS:
I;V) F ESTATES DR
THOMAS WEBER
PERMIT 110.0 5 080152
OWNER'S NAME:
FERMITMSUBOATE
THOMAS WEBER
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SANITARY N0, CONTROL NO.
ARCH=1ENGINEER:
BUILDING PERMIT INFO
BLDG ELECT PLUME MECH
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LICENSED CONTRACTOR'S DECLARATION
Job Description
1 hereby ormn mat 1 am licensed under provisions of Chapter 9 (commeming
with Section 70110) of Division 3 of the Business and Professions Code, and my license is
In full force and ef(em
Lleanm Class Lk.g
Dam contractor
INSTALL 3 WINDOWS/REP CHIMNEY,
OUTLETS/STUCCO N. WAL ^In i . �j aQj
ARCHITECTS DECLARATION
E DECLARATION
"Y `!�1
1 undcrwnd my plans CHIT used u public
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ED
Lhreued Professor"]
OWNER -BUILDER DECLARATION
I hereby ofnrm that I am exempt From the Convectors License Law for the
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following macer. (section 703 1.5, Business and Professions Code: Any city or county
which requires a permit to construct, aloes improve, demolish, or repair any structure
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prior m its issuance. alto mqulres the applicant forsuch permit to rile a signed Yammer
mar he is licensed pursuant to Ith provisions ofthe Conuscmr's license Law (Chapter 9
Sq. Ft. Floor Area "�Il
Valua%2500
(commencing with Section 7000) of Division 3 of the Business and Professions Code) or
L �h
Net he Is exempt therefrom and the basis for the alleged exemption. Any viola0on of
AIN Number
O10 ancy Type
section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of
not more man five hundred doll. (1000),
36925028.00
❑ I.asowoer oFUa pmprny,mmy emplo)as with wagau me4 cele mmpew0on.
will do the work and due smcwrt isnotimeMN cronered fouam(Sec. 7044, Business
Required Inspections
and ProfetslOna Code: Tam COnucmLt.. Law does oat apply m an owner of
ers q p
property who builds m improsea thereon, and who does such wok himsel f or though his
own employees, provided that such Improvements are natimended aroffered formic. If.
however, Ne building ar improvement Is mid within arc you of cempiction. the Owner.
builder win have the burden of proving that he did set Wild or Impose fa purpase, of
sale.).
rs
f/yN1 As owner of the property, am exclusively contracting with licensed conucmm
4swct 7044, Business Profeadans Code:) The Contractors LI-
the project (Sec. and
cense law dors not apply to an ownerof property who builds or improv Marten, and
_
who contracts for such projects with a eonuacmr(s) licensed pursuant to the Commounrs
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LmenseLaw.
❑I'me pi undo Sec .B A, PC(m this n
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Owner l Nr W JV4F V— Dam I -0
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- WORKERS COMPENSATION DECLARATION
I hereby a01under Faulty of perjury arc of the following declarations:
mn
I ham and will maintain a Cerdriesm ofCONent to self-INum for Worlaxo
e Camp-
'
Wime, u provided (m by Section 37M of the labor Cath, far me performance of me
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workforwhiehthis permit isissued.
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❑ 1 have and will maim din Womm's Compensation morsnce, u required by Section
3700 of the labor Code. for the performance of Me work for which Nis permit is issued.
My Wormeg Compensation Insurance carrier and Policy number are;
Carrier. Policy No,: _
CERTIFICATE OF EKEMPITON FROM WORKERS'
COMPENSATION INSURANCE
Mrs section mod not becompmmd if the Permit s far one hundred doll. ($1013)
or leu)
1 ceni(y Not to the perform arm of Me wart For which mis permit is issued. I shall not
emPloy any pacer in any manV=Jobccomembject in the WorkenY Compensation
Laws of CeOfornia. Data Ytaii VVDD
Applicant %,4 %,'—
NOTICE TO APPLICANT. If. after making rob Ccnificate of Exemption, you should
become subject to the WMlUAr3 COMPCMaller provisions of the lahm Code. You most
forthwith comply with such Provisions or this Permit shaft be decmod revoked.
CONSTRUCTION LENDING AGENCY
1 hereby alarm that mere Ina construction lending agency I'or the pafianna cc of
the work for which this permit 4 issued (Sec. 3097. Civ. C.)
Lenders Name
,
-
Landers Address
I certify mat I have road this applanation and mute to me on. information U
coma I agree to comply with all city and county ordinances and rote laws relating to
building construction, and hereby authorise representeiv of this city to enter upon the
above-mentioned property for inspection purposes.
(We) agree to on, indemnify and keep harmless the City of Cupertino against
liabilities. judgments, costs And expeream which may in my way amus against said City
in consequence of the granting of this permiL
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NO11-POINT
Issued by: Date
SOURCE REGULATIONS. - Fv /
Re -roofs
Type of Roof
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SignalamHAZARDOUafA temMRD00Ir DateS MATERIALS DISCLOSURE
WIII or founi building Yom or hmldan huallous material
sec Chapter
Asthe Cupertino Municipal Code, Chapter 9.11. and the Health and Safely
rived y t e Cupertino
io
Code, 0 Section 25532(a)? C(
❑Yes [J No
All roofs shall be inspected prior to any roofing material being installed.
ihazodous
If a roof is installed without first obtaining an inspection, I agree to remove
Will the applicant or future Wading Occupant use equipment m devices which
air cmtsminants as donned by the Bay Area Air Quality Management
all new materials for inspection.
isvim]
❑Yes molu
I have real the huamtws materials requirements under CMPmr&95 of the Collar.
me Health& SafmyCadc, Sections 25505.25533 And 25534. 1 understand Met lithe Wilding
does Out currently hart a moms, that it u my resp rohility to notify the Occupant of me
mqumements which must bemclpd�urmiasuanco of a Certificate cp
Signature of Applicant Date
I r4M N �fUJV`e�-- \� gy
All roof coverings to be Class "B" or better
Owner In
Authorized agent Dam