04040088 CITY OF CUPERI'INO
BUILDING DIVISION PERMIT ? C,QNT4aeT0R INF.QRMt#T7QN.
BUILDING ADDRESS: PERMIT NOQ 4 04 0 0.8 8
7141 LINDY LN
IRE NAME: PERMIT ISSUE DATE
ROBERT ANDONIAN 2004
E: SANITARY NO. CONTROL NO.
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ARCIIITECT/ENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
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0 o LICENSED CONTRACTOR'S DECLARATION
rd I hereby affirm that I am licensed under provisions of Chapter 9(commencing Job Description
�� with Scction]IXX17nbDivixien Sof the Busi end Professions Code.and myliccnm is �'����`
z �n'mllamC apderreel. L1f,�l / Z8' REMODEL MS BATHROOM/CLOSET ■s■w^I/■
;�� oleo` cnmmnor CONTRACTOR: REHDER CONST IN
ARCHITECTS DEC ATI p '
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Licensed Professional 8 understand my plans shall he used as public records
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j OWNER-BUILDER DECLARATION
I hereby affirm that 1 am exempt from the Contractor's License Law for the
❑O following reason.(Section 7031.5,Business and Professions Code:Any city or county
K m which requires a permit to construct,alter,improve,domolish,Or repair any structure
°ya
Prior oits iaxumce.also requires the applicant branch permit to file asignedstatement
y that he is licensed pursuant bsthe provisionsofthe Contractor's Lurroa,Law(Chapter 9 Sq. Ft.Floor Area u
a+ O (commencing with Section 7000)of Division 3 of the Business and Professions Code)or
y Nat he is exempt therefrom and the basis for Ne alleged exemption.Any violation of
Section 7031.5 by any applicant for a permit subjects the applicant to a civil penNty of APN Number Occupancy Type
not mord Than Eve hundred traders($500). 3562 70I700
D 1,as owner of the property,or my employees with wages a their sole compensation,
will do the work,and the structure is not intended or offered for sale(See.7044,Business
and Professions Code:The Conuador's License Law does not apply to an owner of Required Inspections
property who builds or improves thereon,and who does such work himselfor through his
Con employees,provided that such improvements are not intended or offered for arta.If.
however,the building or improvement is sold within one year of completion,the owner-
builder will have the burden of proving that he did not Wild or improve for purpose of
sale.).
(D 1,as owner of the property,am exclusively contracting with licensed contractors to
construct he project(Sec.7W,Business and Professions Code:)The Contractor's Li.
come law docs not apply to an owner of propony who builds or improves thereon,and
who convacts for such projects with a contranor(s)licensed pursuant to the Contractors
License Law.
0/'�J,Wcrmmd
m exempt under Sec. .B&P C to,this reason
Data
WORKER'S COMPENSATION DECLARATION
I hereby affmt under penally of perjury one of the following declarations:
will maintain a Ce tifi.ma of Cnnsenl to self-insure for WmkcrsConapcn-
sation,as provided for by Section 37110 of the Labor Code,for the performer of the
work for which this permit striated.
❑I have and will maintain Worker's Compensation Insurance,as required by Section
37M of the Labor Cade,for to performance of the work for which this Permit is issued.
My Worker's Compensation lnsumnee carrier and Policy rudder am- —
Camfr: 1�fT rI�NP7 Polley Nb-��
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CERTIFICATEOMPE SATIONII NFRANCEORKERS'
COMPENSATION INSURANCE
(This section need nal he cnmplem l if the permit is puma hundred dollars($10))
loss.)
I certify Out in the performance of the work for which this permit is issued,1 shall not
employ any person in any manner an as to become subject to the WorkersCom onsmion
Laws of California.Date
Appacam
NOTICE TO APPLICANT.If,after making this Ccniricam of Exemption,you should
become subject to the Worker's Compensation provisions of the Labor Code,you must
.J Z forthwith comply with such provisions or this permit shall W deemed remked.
'ZCONSTRUCTION LENDING AGENCY
O
'rpt I hereby affirm that them is a construction lending agency for the performance of
a the work fur which this permit Is issued(Sec.3(197,Cih,C.)
W Lender's Name '
z Lcnder's Address
U C I certify that I have read this application and state that the above information is
(y P donees.l agree m comply with all city and County ordinances and state laws relating to
pU building construction,and hereby aothorim representatives of this city to enter upon the
,tea above mentioned property per inspection purposes.
(We)arm.to save,indemnify end keep harmless the City of Cupcnino against
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liabilities,judgments,costs and expenses which may in any way accord xNm1l said City p�
U^tat
e.fLhe S
APPLICANTUNDSTANIIng IAll sID WILL COMPLY WITH ALL ON-POINT Issued by: Date lf/
SOURCEREGUL ION
b Re-roofs
Si a
OfAromficanal.
Contractoram
HAZARDOUS MATERIALS DISCLOSURE—>' Type of Roof
Will the applicant or future building Occupant amre or handle hemdous material
as defined by the Cupertino Municipal,Code.Chapter 9.12,and the Health and Safety
't Section 25532(a)?
is
All roofs shall be inspected prior to any roofing material being installed.
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Will the applicant nr future building occupant use equipment or devices which If a roof is installed without first obtaining an inspection,I agree to remove
tit hucardous air conmminanor as defined by the Bay Arca Air Quality Management all new materials for inspection.
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1 have read the hevardousmamfials mi,ai cmenu under Chap¢r 6.95 of the Carlo,
nia Health&Safety Code,Seeduns 25505.25533 and 25534.1 underamnd Not if the building
does not currently have a Ienanl,dual it is my responsibility In notify the Occupant of the
requirements sh maxi bent prions issuanccnfaccNBcam of ad and Signature of Applicant Date
Goner authorized aper „u - - All roof coverings to be Class "B"or better