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CITY OF CUPERTINO
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DIVISION PERMIT
61co RAG�TOR INFORMATION
BUILDING
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BUILDING ADDRESS:
PERMIT N004 0 3 012 9
10050 IMP RTAT. AVR
OWNER'S NAME:
PERMIT ISSUE DATE
DR. GLORIA LO
INE:
SANITARY NO. CONTROL NO.
ARCHITECfyENGiNEER:
BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
0 0 0 0
LICENSED CONTRACTOR'S DECLARATION
Job DCSCrIpIIOn
1 hereby affirm that I am licensed under provisions of Chapter 9 (commencing
Lithith Scc ton 7001gq of Division 3 oldie Bo!9V Orad Professions Code, and my license is
fo dcffect. lV 37
TI--PEDITRIAN OFFICE
License
Dam �U conuanory f_
CrOO�V�aTnOENZIE BUILDERS (04/28/04)
DECLA� f<
xai�ARCHITECTS
undcraanJ my Plans shall be utiJsspuhl mcarJs
�Llt� ���\'�'�J��(�9IIl� IIIIL���//ll
Licensed Prefcssional
OWNER -BUILDER DECLARATION
1 hereby affirm Nal 1 am exempt form the Conuaco is License Law for the
1�� Ir t)�(t
MOO
following mason. (Section 71131.5, Business and Pofessions Code: Any city or county
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which requires a permit to Conswct. alma improve, demolish, m repair any structure
prion. ox issuance, also mquirea she applicant for such permit m file a signed statement
that he is licensed pursuant the provisions or the C.ntmcmrs License Law (Chapter 9
(commencing with Section 7000) of Division 3 of the Business and Professions Code) or
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Valu4�l'1 1351
Out he is attempt thcarrom and the basis for the alleged exemption. Any vicialfort or
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— `' - — umber "
Occupancy Type
Section 7031.5 by any applicant for a Permit the applkanuo acivil penalty of
not more than five hundred dollars (5500).
35717069.00
❑ L u the P amy wage u Ne'v
-
Required Inspections
Buginen.
ooded offered(Sec. 701Business
will work. e structureof hooded
the wars. and
theswnum is not imm�dcdeLaw
dos .1 Illy an sm
Pr e: door dans tort apply lf an net
carie: The conuanon.
pandro ertywh builds is
and who daessuin work himself his
Ih rad who
or ed
edthrough
own that improvements moRerW If,
awn a
employ=.
ns, pmvided that such imprommenu arc not ear
thefurow.
withinoneyearofimproeforNeowner-
er. the ofo
however.theavetebding rden movinment
g .1 he
builder will have the burden of proving Nat he did not build or improve far purpose of
o
sok.).
1, as owner of the property, am exclusively contracting with licensed contractors m
consumer the pmjem (Sec. ?OTC, Business and Professions Cade:) The C^nuacmts Lh
came law dose not apply to in owner of property who builds or improves thereon, and
who contracts for such projects with a conuzctor(s) licensed pursaam m the Contract..
ense Lew.
1 an exempt under Sec. . B k P C for this rtason
ncr DamWORKER'S
COMPENSATION DECLARATION
;rk
1 hereby Num under penalty of perjury one of the following daclarau0m:
1 have and will maintain a Ceruficam of Continuo self -insure fm Worker'sCompen-
as pmvided for by Section 3700 of Ne labor Code, for the performanco of thewo
for which this permit is issued.
❑ 1 have and will maintain Workers Compensation Insurance, ss requited by Section
37000 of the labor Calc, for the pmformance of doe work for which thu permit is issued.
My Workers Compensation Insurance carrier and Policy number art:
Camra Polity N
CERTIFICATE OF EXEMPnON WORKERS'
COMPENSATION INSURANCE
(This section need not M completed if the permit is furan hundred dollars (51IXB
,
into .)
1 semi that in the rfnmunec of the work for which Nis mit is issued. l shall not
employ any persom manncrm m cpmrsub{moo the Workers' Compensation
Laws of Calif.rn' •� 'D7I7i
Appl'TO
NOTI 0 ANT: It. after making this Cenificam of Exemption, you should
btto a bjmt the Worker's Compensation provisions of the labor Cock, you mug
forthwith comply with such provisions or this permit shall be deemed tevaked.
CONSTRUCTION LENDING AGENCY
1 hereby affirm that them is construction lendingagency Ice the performance of
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the work for which Nu Permit hi issued (Stt. ]0970, Co,iv. CJ
Name
LeaLander's
Add
l<ndcr's Address
1 certify Net I have read this application and stale Nit the above infomutiva is
cotutt I agree ct comply with all city and county nNinanas and slam laws Wing m
hembyacconaemprcunutives of this city to enter upon the
buiwe-maon r
redmn,and
mrimpcfyan
above-(Weiagree
to aveerly
(We) agree t. save, indemnify and keep harmless the against
loop
ac of
y against
incoive;jode,. thecoma.,capesueswhich may in any way accore against said City
U
APPLICANTIUNDERro ANOStAND WILL COMPLY WITH ALL NON -POINT
Issued by: e
S NS.
Re -roofs
Type Of Roof
pp
OUS MATERIALS DISCLOSURE Dem
am,
Will icapplicant future building Occupant store orhatWk haxonlousmatinal
as defined by the Cupenom Municipal Code. Chapter 9.12, and the Health and Safety
Cork, Section 25532(1)?
All roofs shall be inspected prior to any roofing material being
installed.❑Yea
Na
If a roof is installed without first obtaining an inspection, I agree to remove
Will to 0 occupant tau equipment or devices which
the applicant or furore b 'Id"'
,it harardnus air conlamif defined by the Bay Arta Air Quality Management
all new materials for inspection.
grist? !
❑Yes Nu
1 have real the hmallous mamrialarequisemenu under Chapler6.95 oldie Califor
nia Hcalth G Safety Code,Sccuons 25505,25533 and 25AC.1 undersand Ihmif the building
dors no, eurcmly have a rata L t it u my responsibility, to notify de Occupant of the
myaire h.na3tx et norto issuance aft Ccmf:cZ rIecupoincy.
Signature of Applicant Date
"�✓
All roof coverings to be Class "B" or,better
Owner d,an -_ dog t