04060168 CITY OF CUPERTINO 3^` ° ",7
BUILDING DIVISION PERMIT ONTPtAC"`TQR��k'd MATIO ^+
BUILDING ADDRESS: PERMITNL04060168
10295 MIRA VISTA AV
OWNER'S NAME: PERMIT IBSUE DATE
LESLIE M FOWLER 20 0 4
E; SANITARY NO. CONTROL NO.
ARCHITECT/ENGINEER: BUILDING PERMIT INFO
BLDG ELECTPLUMB MECH
LICENSED CONTRACTOR'S DECLARATION
1 hereby affum Nat 1 am licensed u tle provisions of Chapter 9(commencing - Job Description
with Soea ,7000)of DIv1310 Sof BaC Bum and Professions Cotic.endmyliccnse is
4 0, inmRg�andeffect, S753g5 REVISION--IN HOUSE USE ONLY
St';: Lies nm Cl a f.lc.a
Comredor H NO NEW PERMIT ISSUED/ORIG. #04030140
p ARCHITECT'S DGCj1MtZ10N
HI understand my plans shall he used u public records C"to
3 G Licensed Professional
OWNER-BUILDER aexempt
to DECLARATION
2I 1 hereby.(firm on 11. exempt Bum tiro Contractor's C e:Any c Law for the
E:o following moan.(Section](131.;Business andimprove,
ve,de inrm Codc:Any city or county
u�9 which rrquires a permit m cnnswcL altar impmvc,ticmnlish,or repair any cwdum
prior m 1%issuance,also requires the applicant forsuch permit m rile a signed statement
that he is licensed pursuant In the provisions of the Contractor's License Law(Chapter 9 Sq.Ft.Floor Area Valuation 0 '
m�m (commencing with Section 7000)of Division 3 of the 13minessmd Professions Code)at
$
that he is exempt therefrom and in,basis for the alleged exemption.Any violation of
Section 7031,5 by any applicant far a Permit subjects the applicant to a civil penalty of APN Number Occupancy e
no,...than five hundred delta.(5500). 35702037 . 00 p yTyp
❑I,as owner ofthe property,or my employees with wages as their sole compensation,
will do the work,and dmavunure is not intended proffered forsale(Sec.7044,Business Required Inspections
and Professions Code:The Conlncbb License Law does not apply to an owner of q p
property who builds or improves thereon,and who does such work himself or through his
own employees,provided thatauch Improvements arc notinbnded moffered faradic.if,
howeve,,the building or improvement I.sold wRhim ooe year of completion,the owner
builder will have the burden of proving that he did amt Wild or improve for purpose of
sal..).
0 1,as owner of the property,am exclusively convening with licensed contractors to
construct the project(Sec.7044,Business and Professions Code:)The Coninelor's Li.
cense law does not apply to an owner of property who Wilds or improves themon,end,
who contracts for such projects with a eonumeam(s)licensed pursuant in the Canuxbr7
License Law. I ,
❑I am exempt under SS�e��(QJ��q�—J.�(¢ B&P C far this rcsson
er"g-n-L✓xeI 46(9A! ; Dam
WORKER'S COMPENSATION DECLARA N
OI hereby aid.under penally of perjury ane of the f wing decimations:
hm and will maintain a CerOficate of consent to selGinsum for Worker's Compete
Milan,at provided for by Section 3700 of the Labor Code.for Bac performance of the
work for which this permit is issued.
1 ban and will maintain Woder'a Cnmpens dd..Insurance,as required by Seni,n
3700 of the labor Code,for the Performance ofthe work for which this permit I.issued.
My Worker's Compensation�In��anmnce carter and Policy number am:
nice 5i;ArGa hw� PolicyNyy.; I Ong �01 ,
CERTIFICATE OF EXEMPnOf4{IlOM WORKERS'
COMPENSATION INSSURANCE
(This section treed not be complebJ if she Imrtnis is for ore huntlmd dnllata(S TOB)
,r ices.)
1 cenify Nat in Bac performance of the work for which this permit is issued.I shall not
employ any person in say...a,so as in become subject.the Workers'Compensation '
Laws of California.Dam
Applicant
NOTICE TO APPLICANT:If,after making this Ctnifcate of Exemption.you should
become subject to the Worker's Compensation provisions of the labor Cade,you must
0 f,rdlwiN comply with such provisions or the permit shall be deemed revoked.
za~N. CONSTRUCTION LENDING AGENCY
[•+ I hereby affirm that Nene is a construction lending agency for the Performance of
lX> the work fur which this permit is issued(Sec.3097.Co.C.)
QLeadc aNamc
U z LcndeYI Address
V ^
Q renee that I have mad this application and sum Net the above information relatiing i¢
V.0 U coiled I agree to comply with all city and county ordinancesof and sub laws miming b
�U .1a.vingconswctiro,and hereby authodmmpresenutivcs of this city reenter upon Nc
�.s W shove-mentioned I. erty savefaremnify an keep
(We)agrees,cove,indemnify and hick harmless w y se of m agrunina against
flabilUZ I.critiea,j.c.ofthecoarctedof this csmit. mainanyway eccne agonal said City
U z Inconsequence of the granting of permit.
�-+ A LI ERE UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT Issued by: 62� Date
5 EREG �jl� Re-roofs
Signature of ApplicmVComo ctor Gelb
HAZARDOUS MATERIALS DISCLOSURE Type of Roof
Will Ne applicant ar forum W Ilding occupant scam or handle hemdou¢material
as defined by the Cupertino Municipal Code.Chapter 9.12,and the HC310 and Safety
Code,Section 25532(x)? All roofs shall be inspected prior to any roofing material being installed.
[_]y. Ql'u
Will thea licant or future building aces ant ase If a roof is installed without first obtaining an inspection,I agree to remove
PP g P equipmentordMana which
t havadnus air contaminants u ticfincd by the Bay Area Air Quality Management all new materials for inspection.
mrict?
❑Yes
1 have mad the huadnu...1ho dsm,mnommunder Chapter6.95ofthe Califm.
ria Hualth&Saf yCode,Sectiou25505.25533 anti25534.I understand man!fine building
tlrca oat tune y have a tenter.th it is my ms- biI nobly dte occupant of the
auqui ten hs muI I InSumee0r �a��ate a . Signature of Applicant Date
t' a 1"y Oat
Owner or authoti'rcd agent Data All roof coverings to be Class"B"or better