03110121 CITY OF CUPERTINO $
BUILDING DIVISION PERMIT CONTRACTOR INFORMATION
T3110121BUILDING ADDRESS: PERMIT .3110121
q PERMIT ISSUE DATE
RICHARD ATSUK0 MADDEN 004
JNE: SANITARY NO. CONTROL NO.
ARCHITECTIENCINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
0 0 0 0
Lion LICENSED CONTRACTOR'S DECLARATION
N F❑ I hereby affirm that I am licensed under provisions Of Chapter 9(commencing Job Description
iW with Section?000)of Division 3 ofthe Business and Professions Code.and my license is
n<a in full force and Affect
$'q=
License Claauc.At 2-STORY SFDWL/LIVING. 1987 SQ FT
Z�, Dam Contractor GARAGE 400 SQ FT
" no ARCH=S DECLARATION
za rs I tindeind my pims shall W used as public rteoms
JyU
3Gy Lx.rued Professional
g OWNER-BUILDER DECLARATION m p�p
1 herchy arthro that I am exempt Gum the Contractors Liecnac law for the Iy®� N L
p o following moon.(Saito 8131.5,Business and Professions Code:Any oily or County
which rtyus u a Patron in a irca th t eller,improve,such
demolish,fi repair any structure
i„
prior mits censed e,alsamyo the provinces
for suehpermiuoncomLaw(Chale a signed mem
w~a< (that cobe es licemeJ pursuant70th)of Disvoe of the Co usiness and Prvclaw(Chapmr9 Sq.Ft. Floor Area � j w �'$1054144Q
(commencing with Scdian]rg0)of Divixion3of the Basin...and Profusinm Code)or I �L/ /005
.. Net he is exempt therefrom and 0te basis for dm alleged exemption.Any violadon of a F— L
Section]031.5 by airy Applicant for a permit subjects the applicmuo A civil renally,of APN Number Occcu Type
not mom On five hundred dollar(SSRI)). p
35717017 . 00 pqq �"
❑Lo ownerk.the ad Onprinfinny,ut re I, employees d with waguath,lane.Compensation,t. s r•^s
And Pr Onwork.Corm: he Comb not intended Law cum not
apply t Ban.owner
of 'Re UI IOtIS�
And property
ora Corm:The mtha on. rad who Law does ml apply m an nwner of
propertywhobuildsorid that
thereon,andwho doessohwork omuIrorthrough his
Own employee.provided Nal such improvements are not intended Opted ed finsidethe ow.r..
builder Nebuilding or improvementis sold within one year or completion.the owmn
builder will have Ibe When of proving Nal he did not Wild or improve for purpose of
Sale.).
B�r`aa owner of the property,am exclusively contracting with licensed cons WM to
construct One project(Sec.704,1,Business and Profusions Code:)The Contractor's U.
coon law dans not apply tom Owner of property who Wilds or improra thereon,and,
who contracts for such projects with a conlractor(s)licensed pursuant ra the ConRmtor's
Lice.law.
❑lam exemptS B&Pcf.,Nis resort
� Bats S=ao 2
WORKERS COMPENSATION DECLARA
1 hereby affirm under penally of perjury one of the Tolle declarations:
1 have and will mdnlain aCcnifiete of Coltscm m sel0insurt for Wohci sCompcm
satlon,u provided for by Section 3]W of On labor Code,for the performance of the
work for which this permit is issued.
❑1 have and will maintain Worker's Compensation InSWN[e,a rtyulrtd by Snetion
371 of the Labor Code,far the perfamlanee of the work for which this permit is issued.
My Workces Compensation Insurance artier and Policy number arc:
Carrier: Policy No.: _
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(rm scctinn need nal W completed iDhe permit is for one hundred dollars(S10r)
or less.)
1 certify,that in Ne performance of the work for which this Permit u issued,l shall not
employ any person in my manner An an in become subject to the WOrkCor'Campenwuan
Laws Of California.Date
Applicant
NOTICE TO APPLICANT:If,after making this Certificate of Exemption,you should
become subject to the Warker's Compensation provisions of the labor Code,you most
.JO faMpe
with comply with such provisions or this permit hail be rt
foamed wkcd.
Z" CONSTRUCTION LENDING AGENCY
T hereby affirm that their is a Construction lending agency for the Performance of
C' the work fur which this permit is issued(See 3097,Ch,Q
W� Q Lenders Nam,
z Lender's Address
V 0 1 certify that I have read this application and sale that the aWve infolmatiun is
f" coram.I aglee to comply with all city and County oNinanm and su¢laws mining in
pU Wilding construction,and hereby aulhorim mpresemelises of this city fa enter upon the
}� show-mentioned property for inspection purposes. f.
e)agree in saw,indemnify and meep,
the
ty Of
ni.0 against
liabilitieWjudgments.costs and expenses which may in any way lscmuc against said City
U z in consequence of the graming of Nis permit
^ APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT Issued by: Date
SOURCEA �F'a C/
J 14
e-roofs
newrt of Applicanl/Conlracfor etc
HAZARDOUS MATERIALS DISCLOSURE Type of Roof
Will the applicant Lir future building acupam stem or handle haurl material
defined by the Cupertino Municipal Code.Chapter 9.11.and the Health and Sarmy
S«don 25532u)? All roofs shall be inspected prior to an roofing material being Installed.
❑Yes 1101"' P P Y g g
win the applicant or roma,WEaing aaPana as,equipment or devices wmm� If a roof is installed without first obtaining an inspection,I agree to remove
mil hanolous air contaminants a defined by the Bay Area Air Qualify Management all new materials for inspection.
District? t '
0 YeAIf
1have tew3 thehasaminsmaterialsre33 And 55 under Chapter6.95if Ne Califon
Tia Health urSafety Code,tecuonshat it 255lland25534.1 WMOdlmdn OCCUP Wilding
fCCi n0l CeRCnlly haK`a Nnan4 that 11 li my rtSpanslM1Blly W nOUY BIA IX:capml Of the
OC rtmmuw Ctpno, $saamcar.C..fieteafOccapan` . Signature of Applicant Date
0 rorauthari'rW agcm £�— All roof coverings to be Class"B" or better