08010010 (2) CITY OF CUPERTINO
BUILDING DIVISION PERMIT '`CON"CRAGQRINFC}ILMATIf:)N :
BUILD NGA gESS: w c PERMRNO.
�04� STEVENS CREEK BLVD BOGC, INC 08010010
OWNER'S NAME: PERMIT LSSUB DATE
VERONA HOMEOWNERS ASSOC 5610 SCOTTS VALLEY DR STE 01/11/2008
IRV ONE: Q n S SANITARY NO. CONTROL NO.
ARCHITEC iENGINEER: BUILDING PERMIT INFO
REV, REPAIR DECK BEAMS & O O PLUMB O
300 LICENSED CONTRACTORS DECLARATION
F 1 hereby aM.Nat I am themed under provisions of Chapusr 9(commencing ..^^' ^ ^^^^ ^^ ••^•• ---Jab-Description
4 with Suction7n)of Di ' Sof Ne Ousi.wd ofesskm Com.an mylimess,.
a Sha in IYII forte and a
gZ Lienee Lk.
5 Daleff— TSDEC
CHITELTS DECLARA O
Z 1 undueun my pians shall be used a public retards
J
SLicenced Professional
O
^0 OWNER-BUILDER DECLARATION
i i E I hereby aRrm that I am exempt from do Comratars License law for the
a o fallowing reason.(Samoa 703 1.5,Business and Professions Cade:My city ar county
$ which requires•permit m masuuch alar.improve,demolW,ar mpair any structure
prior k its issuance,also requires the applicant for such Permit an rile a signed statement
< fiat W is licensed pursuant to Na provisions of the Contractor's license Law(Chapter 9 Sq.Ft. Floor Area Valuation
9 (commencing with Suction 10D0)of Division J of tie Business and Profession Case)or
^ Nu W is esempt Nnefrom and the buts far the alleged eumpmon.An,vioWien of
Section 7011.5 by my applicant fora permit subjects the applicant to a civil penalty of APN Number Occupancy Type
not mare Nan fl.hundred dollus(55001 P Y YP
' ❑I.uawoerofmiepmputy.nmywplay wMwguudehmkampenudon.
willdedtcworkandthen umuwiIntendedoraffmdfes We(Sm.701a,Bu mess
and Professions Cade:The Canumtah License Law dead WE apply le an awrer of Required Inspections
property who builds or improvad thereon,and who des web wort himself ser through his
own employees,provided Na such improvements art not Intended oroRercd for ale B,
howewn Ne Wilding or Improveroat Is said within ow,Year decrepitation.clue owner-
builder will low the base=of poring that W did net Wild or improve for purpose of
sale.).
❑1,as awns of the property,am exclusively conaaning with Iimmrd cont racon to
construct the project(Sec.1044.Business aM Professions Cade)The[museum's U.
gess law dean not apply to an owner of property who Wilds or improves thereon,and,
who contracts for such projects with acomextor(a)licensed pursuant to the Gnuaemh
License Law.
❑I not exempt under See .B@PC for this mown
Owner Dao
WORKER'S COMPENSATION DECLARATION
1 thereby&Man under penalty of perjury arc of the following declantiom:
1 haw and will maintain a Certificate ofCoadent to ulf-laum far workers compen-
ution,u provided for by Section 3700 of Ne labor Cade,for Its performance of the
wast for which this permit is issued.
❑1 haw and will maintain W~s Compensation Imutana,as required by section
3700"Ne Labor Cade,fm N erfamtaneafthe wort for which this permit's issued
My We me enation 1 sum ce car and Policy n
Grtier. Rey No.:
CERTIACA OFEKEI ONFROM ERS
COMPENSATION INSURANCE
(Otis sante need not W completed If Ne Permit k far.hundrtdda0an($100)
Or kna)
1 certify that in the performance of the wade for which this permit is issued,l shall net
employ any person in any roamer an as to became subject in the Warteri CompeuNon
Laws of California.Data
Applicant
NOTICE TO APPLICANT.IL after making this Ccrdricam of Exemption,yes Amk
become wbjact as the Wahcti Compensation provisions of the labor Cade,you mum
0 forthwith comply with such provisions or Nu permit shall he deemed revoked.
„'�„ 1 CONSTRUCTION LENDING AGENCY
I heroby afures into Nem is a construction lending agency for the Mrfosromm of
Cw > No work for which this permit is Tuned(Sad.3097,Civ.C.)
QLanders Name ,
z Lenders Address
U p I enlfy that 1 have read this aPPIICmOn and nen that Ne aWw InfmmWan 6
Lfw toren 1 gree to comply with all city and county ordinances and sign laws relating in
�C) Wilding couumman,and Wreby wNodae MimsmtsWm of this city in ener upon the
W aWw-mmdaned property for inspection purposes
1% (We)agree to saw,indemnify and keep harmless the City of Cupertino gaunt
fA Ihbilimad.Jud{menu.cone and expenses which may in any way acme against said City
U Z in co mattes ee of the gsanfing of this permit. Y
^" APPLICANT UNDERSTANDS AND WI LY WITH ALL NO -P01 Issued b : Date
SOURCE RECU Ns. /
Si{ Re-roofs
nu ofA cartaZm r Dan
DOUS MATERIALS DISCLOSURE Type of Roof
Will the applicant or future building accupantsnrc or handle haardom material
a de0ncd by Ne Cupenino Munich I Code,Chapter 9.12.and the Health and Safety
Cork,Section z55Ja(a)7 N All roofs shall be inspected prior to any roofing material being installed.
Will the applicant or future Xildi.g antpmt use equipment Or devices which If a roof is installed without first obtaining an inspection,.I agree to remove
it h ewmas air common anu defined by the Bay Area At,Quality Management all new materials for inspection.
Dive e,7
❑Yes u
I have rend the laudations;mattgql1ais requirements under Chapter 6.95 of the Califor.
nis HUINh Safety Cade,Suctiw75705.755JJ uW 25534.1 urdersorcd thuif de Wilding
done lest currently veaewq NU ltismy mT an Ytie acupantaf
mquiuments whian Signature of Applicant Date
Wmet arm is ¢Card&, TOcapry/�/ All roof coverings to be Class"B"or better
Owner auNemed¢gem D'