04060157 CITY OF CUPERTINO 1lCONTRACTOR°INFORMA IONI
BUILDING DIVISION PERMIT
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BUILDING ADDRESS: BRIAN STROM PE""NO04060157
OWNER'S NAME: PERMIT ISSUE DATE
iBRIAN STRO
E: SANDIA NO. CONHOL NO.
ARCHITECT/ENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MACH
0 D Q O
�tsp Zp LICENSED CONTRACTOR'S DECLARATION MJob Description
dz 1 hereby affirm that m
at 1 me licensed under provisions or Chapter 9(comencing P
< with Satian7001A.1'DIAMOn 3 of Ne Anne.and Profession.Code,andmylicomo6
M
'qin full force and affect, INSTALL DECK & BBQ
Z U...ClassLb.a .
ntractor
ARCHITECT'S DECLARATION
'Sy 1 underuend my plans shall M used a public records
3 G Licensed Profruional
OWNER—BUILDER DECLARATION
E 1 hereby.(Rtm that I aril mumps from Ile Gonion Co License law for the
OO
following mason.(Salon]onsumr,Business and Profession Code:Any city or county
$ which requires•pom,lr re consumer,aloe improve,deermit t ere a sig ed tuucmre
pat heir issuance.mscdpursu requires toithe prevision
of for sochpennrrrofilnse signedstatement
F OtilathrroncigwithSectionTOIAofDivisionoftheBusiness
the uinessnimneclaw(Chapta9 Sq.Ft. Floor Area �., Valuation
m (cum a is axe pt Section and
of Division f r of the Bu d assure d Proon.M vi Cale)or
.. Net he Is exempt therefrom mtl the basis for On alleged assumption.My violation of
Section 7031.5 by my applicant for a permit subjects the applicMl in a civil penalty of 3 6Q*IIQa'h1er0 0 ,Occupancy Type
not more Nm Ave hundred dollen($500).
❑Las owner ofthe property,or my employees with walnut as their sole compensidon;
wilidolhewol,and thesuuctum is notinundeda offend fosale(Sec.]ON,Business Required Inspections
and Communes Code:The Comunes Liam Law does ml apply to in owner of q P
property who but lds m improve.thereon.end who does such work himsel f or through his
own employees,provided that such improvements am not intended oroRertd far We.if.
however.the building or improvement is cold within aro year of completion.des Owner.
Wilder NB have the burden of proving that he did not build or improve for purpose of
nils).
g 1,u Owner of the property.am exclusively contracting with licensed contrantoe to
CQtttrecl the pmjm(Sec.7044,Business and Profeesioes Code:)The Commaux'e Li.
cease law does not apply In an anter of property who Wilds or improves Amnon.and
who contracts for such pmjeeu with a convscmr(s)licensed pummnt to the Committees
L xnso
❑I am exempt under Sec. —.B h P C for this reason
s tar t�Q,�ti: �Ite 6 g
ORTY K It'SA ON'PI RATION
I 1 hereby.Man under penalty of perjury one of the following declarations: l
have and will mainmin aCertifimieof Consentm Ylf-insum fa War cr's Compcn-
salon,no provided for by Section 3700 of de labor Code,for the performance of the
work for which this permit is issued.
❑I haw and will maintain Walker'!Compensation Insurance,as,Idlumod by Section
37M of the labor Code,fa Ne performance of the work for which this permit Is issued.
My Worker's Compensation Insurance renin are Policy number art:
Center. Policy No.: '
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(rale rection reed ant becompleted if the permit is foram hundreddollars(SIM)
or leu)
I anify that in the performance of Ate work for which Its permit is intend,I shall nes „
employ any person in any menncrm ss to Wcomesobject to the Workers'Compensation '
Laws of California.Dau
Applicant
NOTICE TO APPLICANT,If.after making this Certificate of Exemption,you ahold
become subject to the Wohcr's Compensation previsions of the Labor Cndc,you must
�Z forthwith comply with srchprovisions orthis Permit mail It,decmcdrevoked.
Z O CONSTRUCTION LENDING AGENCY
[^—t I hemhy AMM Nat then is a construction lending agency for the performance of
ly$7 the work fur which this permit ts issued(Sec.3097,Cih,C.)
GQ Lmdces Name
=z Lender's Address
U O I certify that 1 Mw mad Ars application and sum Nat the above Information is
Ig,F cermet I agree to comply with all city and county oeinmms and sue laws relating m
O U Wilding construction,and hereby audamim reprtxntNvea of this city to now upon Ave'
w above-menlonW property for inspection parpmY.
,f�y1 G (We)agree to ova,indemnify and Frap harmless the City of Cupcnim against
jy rA Ilxbilities.judgments.coats and..passes which may in my way seethe againn said City
U Z in consequence of the granting of this permit.
w, APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT Issued by; Date
:Wfil
EGU TION .
6 7Ao Re-roofs
f AMlicanACOntmmr Be
HAZARDOUS MATERIALS DISCLOSURE Type of Roof
the appllcent or future building�ccupanteorc or handle heYeous material
by the Cupertino Municipal Code,Chapter 9.11,and the Health and Safety
nn 15531(.)7 All roofs shall be inspected prior to any roofing material being installed.
es �NO
the applicant or
tutu building Occupant tote equipment or devices which If a roof is installed without first obtaining an inspection,I agree to remove
oes air conuminants ss defined by the Bay Area Air Quality Management all new materials for inspection.
❑Yen �o
I haw tad the Iwamoto mareAals requirements under Chapter 6.95 of the Califar- 1
nu Heal"Safety Code,Sections;35505.25533 and 15534.1 undcmunE that if tM Wilding
does nor currently an•tmanI, u his my rest mulMlity to ratify ft occupant of the
regni m is which mer Yissumm.f.certifc.w.facmpar / Signature Applicant Date
tYv g PP All roof coverings to be Class"B"or better
icr or authoriatda cm