05030122 CITY OF CUPERTINOBUILDING DIVISION PERMIT
ON CTURihNF.ORMt1.
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BUILDING ADDRESS: �7 - PERMITNO.05030122
B4
ER'S NAME: PERMIT ISSUEDATE
BUNKER GREGG C 02/23/2006
PFUNE: SANITARY NO. CONTROL NO.
ARCHITECT/ENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
300 LICENSED CONTRACTOR'S DECLARATION Job Description
sit 1 bersby•Tum that l sm licensed under previvan of Chapter 9(commencing
IN Section 7")of Division 3 of the Business and Profcations Code,and my license is
m� Ofullfomeendcnea CONDO-3 STORY (2 , 682 ' LIVING)
514 Dam Clsss Long NEW ADDR WILL BE ASSIGN ON WILDFLOWER WAY
ARCHITECTS DECLARATION
I understanJ my ptans NJI be used u public rtcmrd
i u
Licensed Professional
OWNErn exempt
DER D the Commerc
.E I hereby.(Rete on I atm exempt from the Conon Co License Law for LM
E following mason.Permit
703 1.5. t.Businessandva.dWnns Cow:Any city structure$ which mquimaspetmh rewires Latter,int fmw,h permits are a sig any Nucwre
Pdartoits issuance.also requites previsions of
for such Mnor'lLiccow aw(Chaned mem
< that On is licensed purso.ntmue pavilions of Ne Contractor's Lkense law(Chapter Sq.Ft.Floor Area Valuation
$ (cote.rch,&with Section 7000)ofDiviian3uftheBusinemandProfmaionsCode)w $321840
that he l exempt therefrom and the basis for the alleged exception.Any Yield=of
Section 7031.3 by any applicant for a permit ubjects the apPlkant to a civil Penalty of APN Number Occupancy Type
not more than firs hundred dollen(SSW).
0 1,as,oww of Ne property,or my employees with wagm as their sole compensation,
will do the work and due atructore is not intended on offmod for sale(Sec.IDM,Business Required Inspections
and Pns rofetooCode:The Conoacter's License Law doer Out apply W an owner of q P
pmpeny who builds or improv thereat.Wwho doorsuch wart himselfartiuoush his
awn employees,provided that such imProremanta art notmeended maffend for sal.IL
hawewr,the building or improvement issold within one year of completion,the owner.
Wilder will have the Wrden of moving that he did net Fund or Improve for purpose of
sale.).
sm 1.as owner of the properly,am maduslvcly
prop ry who Wild,
with licensed conwnun to
construct the project(Sec,7004.Bminev and Professions Code:)The Contractor's Li.
tome law dace not apply je an owns of r cm I..wbo builds or ood WImpreven duertan,and
who contracts for such projects widua eonvactor(a)licensed punwnt toth Convanofs
Lken n mom
em
❑1 am expt under Sec. .B&P C for thio reuun
er
Data
WORKER'S COMPENSATION DECLARATION
1 hemby storm under penalty of perjury can of lie following declan0ons:
O l have and will maintain sCertiftmm of Cement w self-Imam IneworeseaCmmpen-
action,w pmvided for by Section 3700 of the Labor Cade.for the performance of the
work for which this Permit is inuei
0 1 have and will maintain Worker's Compensation Insurance.as required by Section
3700 of the Labor Code,for the performance of the work for which this permit is Issued.
My Worker's Compensation Wursnce carrier and Polity number lie:
Cartier. Policy No.:
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
Cris account reed trot be com pleted lithe permit is for site hundred dollen(5100)
or leas.)
I certify that In due performance of the work for which this permit It Issued.I shall not
employ any person In any manner an as to become subject to tie Worker's Carnpensstion
laws of Califomie.Date
Applicant
NOTICE TO APPLICANT:If,after making this Ceninau of Exemption.you should
become subject to the Workees Comp:esauan provisions of she Lahr Codc,you muss
,JD forthwith with comply with such provisions or ibis Permail Ina deemed revoked.
Z v~Nr CONSTRUCTION LENDING AGENCY
(.r I hereby affirm that then is construction lending agency for the Icrfurmana of
f1v 7 the work for which this permit Is issued(Sec.3W7,Civ.C.)
W Q fender's Name
z lender's Address .
U Q 1 certify dust 1 have read Ibis application and cute that sac above Werneauun I-
Is,
ley F coney I agree to comply with JI city and county ordinances and sou laws relating to
0 V building construction,and hereby auuorl7e mmmenmives of Ibis city to enter upon the
W above-mentioned property for inspection purpOW L
fit (We)agree In ave,indemnify and keep harmless the City of Cupertino against
rA Iiabitida,judgrmnu.coau andexperea which may in any way ac=apinat said City
()r7r in consequence of the Swung of this permit.
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT Issued by: Date 7. '`2-7'B�
SOURCE REGULATIONS.
Re-roofs
Signuurt of Appllcan RDO Dete
HAZARDOUS MATERIALS DISCLOSURE Type of Roof
Will saceCupeapplicant or fMurt Wilding Occupant Chapter
reamar handle Health and
u defined by the CupeNno Municipal Code.Chapter 9.11.and the Hcdu and Safety
Section 25531()? All roofs shall be inspected prior to any roofing material being installed.
❑Yue ONO
Will the applicant or future building occupam use,equipment or devices which If a roof is installed without first obtaining an inspection,I agree to remove
emit hamrdnus air contaminants as donned by the Bay Arm Air Quality Management all new materials for inspection.
District?
0Yes No
I have read the hm udous materials requirements undcrChapter A93 of the Collor.
Cis Hcaldu&SafctyCodc.Settimo 13505,13533 and 25334.1 usecrrund that iftie Wilding
dos not currently have a immi.Net It Is my respomihnity W noufy the occupant of the
requirements which moat be mel prior W issuance of a CmdfmM of Occupancy. Signature Of Applicant Date
Owner oraathorindagent Dote All roof coverings to be Class "B"or better c