03100215 CITY OF CUPERTINO +'''+�
BUILDING DIVISION PERMIT CONTROCTOli^INFORMA.TION
BUILDING ADDRESS: PERMIT NO03100215
03100215
OWNER'S NAME: PERMIT ISSUE DATE
Aift VIC
,NE: SANITARY ONTROL N0.
ARCHITECT(ENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
+sop
LICENSEDCONTRACTORDECLARATION
u Scene.hereby arfinn that I am fthe Be under provivoas ti C ods, 9(commencing lob Description
withll(me]it effect. 3.f the eusinea and Profcasinm Code,and my license in
I.LicenlseClassndeffat. Lleg NEW 2-STORY SINGLE FAMILY DWELLING
�F Dam Contractor LIVING SPACE 3816 SQ. FT. /GARAGE 657 SQ. FT.
EE ARCHITECT'S DECLARATION
1 understand my plans shall W mind as public records �uma�B
'6G �IYFN
it. Licenced Professional /sa I7 E
OWNER-BUILDER DECLARATION ///ryplyl tpti�e
.�<F I hereby.socc Net 1 1. esempl from tit Conmanofa l:Any c Law for the
_D o following reahar.(Satan IIDL.S,s,ihBusiness and P .dem as Cade:Any city or county
$ which squires issuance.pmmit tar erns,the ptree,improv,h Permit t fi repair any tatuaure
priormitsensedatrantmile the of for such Permit coaxfile Law ned
mm< that W is licensed pursuanuo the previsions of Ne Contractor's Licenm law(Chepmr 9 Sq.Ft. Floor Area O O
in (commencing with Section 7000)of Division 3 of Ne Business and Professions Code)or
y $ that K u exempt therefrom and the basis for the alleged camp ion.My violation of
Sccdon 7031.5 by arty appliant fora permit subje the applicanna a dvil pealty of APN Number rreei+tt OgccT"an Xnot more Nan fiw hundred dollars(5500). 32619005 . 00 tl L4m A pt
I,asawner of the pmpmty,amy emplaycrs with wegas as their sob compenatm,
will da Professors
work,ands: he Connsonotintendedo Law
toad,Busiow
dna propPrue hons Cade:The wsthecton License who law darn oat apply lf rt maser of Required Inspections
own em whos,proceed tat such imp(werems docsamh work himalfed for Weugh his
own employees, Nat such improwmenu ere not intruded W oBered for sale.I.
builder.the buildingorimprovement ishathwithin one Wild
or comm Fier throw of
builder will how the burden of proving Net W did not build a imPmw fa purpose of
J.
I,u comer of drc propeny,am exclusivdy cmmacting with licensed contlacmrs m
tract the project(Sec.7014.Business and Professions Coact)The Contractors Li-
ccase law does not apply to an owner of property who Wilds or improves Nemo.and
who contracts for such projects with a conuacmr(s)licensed Museum w the Conommes
tense law.
❑I sm exempt unam Sec. .B a P C for Nu mason
Owner Data 2-73 Gk
� WORT I7M ^NSATION gEC1.ARATION
1 hereby affum pe
under penalty of rjury oma`uC1following declarations:
❑Itoward will..low..Cwtifiare of Coasem to self-howsforwartencompcn-
shon,as provided for by Section 3700 or Ne labor Code,for the performance of the
work for which Nis permit is issued
1 haw and will maintain Worker's Compensation Insurance,ut rtquimtl by Secum,
3700.f Ne IaWr Code,for the perfmmancc of the work for which Nis permit is horned.
My Workers Competiaton Is.canine and Policy num W,art:
Carrier: Policy No.:
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(Inds scrum reed act W completed Ifth purest is for one hundred dollars(SIM)
or leu.)
I certify Net in the performance of the work for which this permit is issued,I shall not
employ any person in any mamncrao as to tecome subject to dr.Workers Compensation
Laws of Califomia.Dam
Applicant
NOTICE TO APPLICANT:If,after making Nu Cenificme of Exemption,you should
become subject to IW Workers Compensation provisions of Ne Labor Code,you most
.J O fo fbMth comply with such provisions or this permit shall W dnemad rcvnked.
Z� CONSTRUCTION LENDING AGENCY
[-� I herebtrafrre Nat Ncrtisacoruhucunnlending agency fw the perfurmame of
C'>
the work for which this permit u issued(Sec.3097,Ci,C.)
W�Q Lender's Name
Z),z Lcrder's Address
U Q I certify that I haw mad Nis application and sum thn IW aWw information is
gl� F corerL T agree to comply wIN all city and county oedbamCa and Stale laws misting N
0 U Wilding construction.and hereby aulhorme reprtamatiws of this city on enter upon Nc
til aMvc-menuoncd pmpc costs
for iespccuon pugwses
(We)agree m ave,indemnify and keep harmless the City of Cupertino against
V Z in witastienom of
osuand expuueswhich may in any way accrue againslsaid City
m consegmna of the grenling of this permiL
^ APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT Issued by: Date
SOURCEREOU
Re-roofs
i
more antraelOr Date
HAZARDOUS MATERIALS DISCLOSURE Type of Roof
Will Ute applicant or future Wilding occupant voce or handle haardeor material
as defined by the Cupenino Municipal Cade.Chapter 9.13,and de,Health and Safety
Code,Sceuon 355330)?
❑Yea 0 N All roofs shall be inspected prior to any roofing material being installed.
Will thea applicant or future Wilding men If a roof is installed without first obtainingan inspection,I agree to remove
GIR PP g e B use ea Air Qui or Mara which p g
DistrictpaNnus air contaminants as defined by the Bay Area Air Quality Management all new materials for inspection.
0Yet C]No
1 have roof the bmaNms materials requirements under Chapter 6.95 of the Coffer.
-is Half 6 SafctyCodc.Savwu]5305.35533 end 25531.1 undcrnuW Nu ifIM Wilding
docs not currently now a tena4 Nm it is my malco sitility in noury the occupant or thc
rcymimmemL ua 6orwimummor&Ccmrcateoroccupmry. Signature of Applicant Date
Z-2-.3-
Ker or a Nwn! agent Dote All roof coverings to be Class'B"or better