04070061 CITY OF CUPERTINO '7 t
BUILDING DIVISION PERMIT ��C.ONTRACTOR�INFORMAT-IO.N
BUILDINCADDRESS; ANTIQUE TERMITE & PEST PERMIT NO.PEST
OWNER'S NAME: PERMIT ISSUE DATE
PHYLLIS WILLIAMSSANITARY �ftll NO.
E:
ARCHITECTIENGINEER: BUILDING-PERMIT PLINFO
BLDG ELECT PLUMB MECH
0 0 0 0
Y00 LICENSED CONTRACIC]R'SDECLARATION
Job Description !�
I F 1 Mrcby affirm IMt 1 am licensed under pmvisians of Chapur 9(commencing Arm®
`af with Smuon7")of Division 3 of lite Business and Note iuro cmic.ubmy�nscis
� i imm�m �4.yetrrm FUNGUS DAMAGE REPAIR (1/2 BATH F Imo$ L. 100
D�_ Lwtnse Ct Gtr
Z r e Daw__yL Contractor FL. JOIST) AUG 2
££ A CHITEC'S DEC" Irl N
I and land my plans shall M used as public records 900
Dy
o Licensed Profeadonal �n/1B
OWNER-BUILDER DECLARATION v 0
i Z 1 Mrcby affirm Nal 1 am ucmpt frum the Cmikenefs lactose law for sht S®,jgrw
O O fallowing reason.(Section 1131.5,Business and Pmfn,ndom Code:Any city of county �t�BO
,29
$9 which requires•permit to condmcL tl m.improve,demolish,or repair,any..to.
Fiy prior to its issuance,also requirnsthe applicant for such Permit torteasigned suumenl FFloArea Value
< indite is licensed pursuantmthcp.visiouofthe ContruSq. [. or
tur'sLicenseLaw(Chapter9 "275
O (commencing with Section 7")of Division 3 of the Business and Professions Code).1
i Nat M is comorn therofrare andftbasis for de alleged carmptiun.Any violation of
section 7031.5 by a"applicant fon Permit bit.the applicant in a cmll penahy Of .APN Number Occupancy Type
not mom thN five hundred dollars(Ss)o1. 35611014 . 00
❑1.m owner of she property,or my employca with wages as their were compensation.
will do the work and Ne structure is not intended W offered for safe(Sm.7044,Business Required Inspections
and Professions Code:The Contractors License Lew does not apply to in owner of q P
pmpeny who builds or improves Comma,and who docs s ue h work himsel f or Wangle his
On employes,provided Nat such improw:menu are not intended oroffemA for sale.If.
however.the Wilding Or improvement u sold within one year of completion,the owom.
Wilder will have the burden of proving that M did am build or impro a for parposc of
sal.j.
ci L as owner of the property.am eaelusively contracting with Incomd Co....to
construct the project(Sec.7D44,Businm and Profusions Code:)The Contractors Li.
ceme law docs not apply W an owner of properly whit builds or improv thereon,and.
who contracts(of such project,with a contranons)lieerokd pursuant in use Canusnees
License law.
O I am exempt under Sec. .B&P C fm Nis moan
Data
W
Owner ORKER'S COMPENSATION DECLARATION
I hereby-Tmv undar pcnslty of perjury On,of the following dmlantiorts:
will maintain a Cenifwte of Consent to self-insure for Workers Compcm
jp�vcmnd
as provided far-section 3700 of the tabor Cade.for the performemu of the
work for which Nis permit is issued.
1 ban and will maintain Worker's Compensation Insurance,as requited by Section
37W of the labor Code.for the pefforman,c of tie work for which this permit is issued.
My Workces`Cam/peruel/t"��n l�urnrt/q artier srM Policy number m:
rJT/1')]Lfa4 0`1 Policy No.:QGA�/ TSI�r1
CERTIFICATE OF E%EMPfIOfy FROM WORKERS'
COMPENSATION INSLRAIRCE
(Thh section need not M completed if the Icrmlt Is forone hundred dollars(SIN)
or less)
I unify that in to performance of the work for which this permit is issued,l shall not
employ any person in any manncrsn as On become subject to the Workers'Corepermtion
Laws of California,Data
Applicant
NOTICE TO APPLICANT:If,after making this Certificate of Exemption,you should
become object to Nc Workce.COmpensauon pmvisbm.of the Leber Code,you masa
Z forshwide comply wish such provisions or this permit shall M deemed revoked.
Z O CONSTRUCTION LENDING AGENCY
[-. 1 hereby affirm Net Chert is a construction lending gency rat the performance of
p:7 to work for which this permit is issued(Sec.3097,Civ.C.)
LUQ lander',Name
D. Lender's Address
UVURI certify Nd I hoe read this application and sone that the W.information a
— cmmn.I agree m comply with all city and county Ordinances and slow laws relating w
QU building construction,and hereby mthods¢pruenmises of this City to enter gg.Ne
Uabove-memiuned property for inspection purposes 1
(Wag agree m love.indemnify and keep harmless Ne City of Cupertino egaina `//
CL. liabilities,judgmcnu,cods and eapeuu which may in any way acerae against said City
(„)z n�pnsegoerue of the granting of this permit. Date
4 0 SI7CANT UNDERSTANDS AND WILL COMPLY M'ITH ALL NON-POINT Issued by:
SOURCE REGULATIONS.
Re-roofs
HAZARDOUS
Signature of AppliaDatee Type of Roof
HAZARDODO US MATERIALS DISCLOSURE
WilltheeCornett"m future Mont buildingoccupantsortoran to Hcardousmaterial
u defined by the Cupertino Munici al Cede.Chapter 9.13,and Nc Health and Safety
cWe.smuon sss3z(a)7 � All roofs shall be inspected prior to any roofing material being installed.
❑Yes
If a roof is installed without first obtaining an inspection,I agree to remove
Will the ireapplicant or future building occupant y A co Air nt or devices which
I7d.
ha'urdnus air conmminanu u/kfncJ ny the Bay Arta Air Quality Managcmtnt all new materials for inspection.
C� itt? -;N
❑Yes Nu
I have reed the Wnrdaus materials requirements under Chapter6.95 of the Califor.
Health k Safety CedC.Sections 25505.15533 and25534.1 understand Natifdw Wilding
no Indy have a wrens Nat it is my mspons)hilii m noury the occupant of thc
� mua cpnmmissuame.m.Ccm amphncy. Signature of Applicant Date
-2'Ay-01 All roof coverings to be Class"B"or better
ner anuth nand agent Dow