08090081 CITY OF CUPERTINO ?:�
BUILDING DIVISION PERMIT RC,ONTR "GI IN URMATION
e rTe,
BUILDING ADDRESS: PERMIT NO.
21124 GREENT.FAF DR TBD — TQ BE D
OWNER'S NAME: PERMIT ISSUE DATE
CONTROL NO.
ARCHMICTPENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
0 0 0 0
3d,
LICENSED CONTRACTOR'S DECLARATION JOb Description
u� 1 herIf¢
hereby AT.tat 1 w nsed under Provisions of CMlner 9(commenIcing P.
^� with&.do.7i]rsfofDivision 3ofte florin.Mm
d Professions Co .od my fees.is
mfullmrcaanderceea 6' S ( S� ADD 926 ' PORCH,LIVING RM, ENTRY,HALL
?pz License Cl Lle.g
F mw J CSDw aU BATH,MASTERSUITE, ATTACHED GARAGE 427 ' (DEMO
ARCHDECPS DECLARATION
f�� IunderwnJmypunsshallWused as public rtenrm EXISTING)REMODEL KITCHEN 250 ' , BATHRM
pr
I iconsed Professional
OWNER-BUILDER DECLARATION
I hereby aRrm Nat I am exempt Imre to Conwtotofs License Law for tM
O O following mason.(Sadao 7031.5.Business and Professions Code:Any city or many
$ which notion a a Permit w examuct.ala.MPre e.demolish,m epmr any tbumurt
Zf poor m its Tishman.also,nolui.weappllCNl fnrpKh permit m file a slgned.marnml
z
go
W is licensed p.m.,tote previsknsOf the Common's U..Iaw(Chspue 9 Sq.Ft.Floor Area ' Valuation
E (commencing wit Section 7000)ofDwaier 3 OftoBualmasmd Professions Code)ur
,at Its u exempt to ufmm and the has for the stayed exemption.My violation of S200425
Section 7031.5 by any applicant for a Permit subjects we applicant 10 a civil Pemlty of APN Number Occupancy m'
ser ream tm fiw hundred milersISMP Y '7ISPe
❑Ianowa of Uw pmputy,mmy wpl%m wit wgeaaste'vtole mmpenssUon, 32628097 , 00
will do to wart.and teseumum u not inu:eded waffared forsale(Sec.7066,Busircas
and Professions m CoThe Cesbame's License law dam an[ant apply as en arm of Required Inspections
property who builds or improv terms.and who does such work himadf ar trough his
awn rand.ya,provided tat such imPruvements an,not intended moRcred for Wa.If,
however,to building or improswmant is told within ane year of completion•the owner-
bellm wi0 hoe to burden Of pro iq drat he did Out build or improve for purpose of
sale.).
❑1.as owner of d o property,am asmusivaly eo=in&with licensed conunnn m
construct the project(Sec 7066.Busing and Profculons Cade:)The Cm4acmeS Li-
cense law da not apply w an owswr of pmpeny who builds or imp om tenon.and.
who contracts fm such pmjeets with a conuowrp)licensed pursuant to to Conutotoh
License law.
❑Ismexamp,tuxim See .B&PCfw,1dsmxmm
Owner Due
WORKER'S COMPENSATION DECLARATION
40 I hereby affirm under penally of perjury one of tM following declarations:
❑I ha.e and will malnuin a Cenfiote ofUnttm w self-insure fru Worker's COmpem
cerise•as provitrd fur by Section 3700 of to tains Code.far the perfores.of d o
work for which tis Permit is issued.
❑I have and will maintain Werkees Compensation Wurance.u required by Section .
37M of the TaborCode.fm the performance Of to work for which to Permit is Issued.
My Worthen.Compensation Wuruee carrier and Polity number ase: g-
Cartier.STS .r-atwl L� Policy No.:
CERTIFl ATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(Thu semlse mW set be complewd Btr puma isforenc hundred dollars;(SIM)
est)
1 certify tit in the perforrame of to work for which tis Permit is issued.)still Out
cmpl%any person in any mmmr to as to become tob*t in the Wo lm s'Compuuason
Lawn of Callfumia.Dam
Ap,H.t
NGnCE ID APPLICANT.If,&Act making this Ccnncaw of Exemption.you should
became subject,in tM Worker's COmpensNon pmviuma of the lahor Code•you muse
.,O forthwith comply with such provisions or to Permit Nall he dmmcd rtwked.
Z M
CONSTRUCTION LENDING AGENCY
I•+ I hmah,afore this Marc is a construction lending agency for to pe Mearns ncc of
C'
the work for which this Permit is Word(sen.397.Civ.C,)
ILl Q lenders Name
=z IcMets Address
U O 1 century drat I haw:read tills,pplieation and saw dull the above iafomiatiun u
V, !' comet I,gree w k comply wit all city ascounty entrances and sae laws rtuting to
.C) SV' building construction.and hereby wtorim represmutim of dru ey w enter open the
W alrovnmcndomd property for inspection purposes
(We)agree to sew:,indemnify ad keep lamless the City of Cupertino against
liabilities,judgments.toss,and expenses which may in any way ammc against said Cly
U z in consequence of the granting of dru P iL
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT Issued by: Date
SOURCE REGULATIONS.
Da Re-roofs
Siy,wurt Of AppliaDataHAZAR
HAZARDOUS
S MATERIALS DISCLOSURE Type of Roof
Will the byft Cupent or rwo Muni Wilding e.Chapter
a Heardans m,wrial
C deRmd by tM Cupertino Municipal Cade.Chaps 9.12.sew tie HWdr and S+Icy
Code.Seed.255324)? All roofs shall be inspected prior to any roofing material being installed.
(]Yu �No
Will we applicant or future Wilding Occupant use equipment or meta which If a roof is installed without first obtaining an inspection,I agree to remove
m
emit haearns air corm
umim us as 0ncd by to Bay Am&At r Quality Management all new materials for inspection.
Disuict7
❑Ya jd No
1 have mad tiw hvanous maiau requirements urea,Chapter 6.95Ofto Califon
.is Health&SAcyCode,San.25505.75533 and 25536.1 undcamed tat iftie Wilding
da ret.annoy Mm a went that it u my responsibility w entry the occupart of dw
requirements which mart W . r=a issammara Cenrcawaf OcmPas%. Signature of Applicant Date
OCT- g�z Owner or wtharimd gen Date All roof coverings to be Class'%¢"or better