08010020 CITY OF CUPERTINO
BUILDING DIVISION PERMIT i{ ,..0NTkXGT.0R,1 ,T�yF�
PERM f NO.
BU
"T.T.QADTTUBB RD TBD — TO BE DETERMINED 08010020
WNER1'SLNAME: 25 PERMIT ISSUE DATE
SANITARY NO. CONTROL O.
ARCHITECTIENGINEER: BUILDING PERMIT INFO
ADD 260 (BDRM#3 , LVNG RM & BLDG ELECT PLUMB MECH
C= 0
u o o LICENSED CONTRACTOR'S DECLARATION _Job Description
1 hereby affirm that I stn licee,cel uMer provivioes of Chapter 9(commencing
2� with Secant lIXlD)of Divides S of the BLLVrCV and Plofe6ioN Code,and my licenac is ^_^^ _ ^_^ ^-- _^`T
o<N in full force said effen.
�q= iso oiaclaaa Lie.0 X7120 �
a Data Cenuscwr 6
W ARCHITECTS DECLARATION
j e< I understand my plans call bo uaeA as public records
oder
a G Licensed professional
OWNER-BUILDER DECLARATION
a� f I Wreby Tom then I me exempt from Ne Canu un'.License Law for Ne
00 rellowing reason.(Section 7031.5,Business and ProtectionistConk:Any city or county
K$ which requires a permit to cont spar,improv.demolhah,or repo,any structure,
YZi prior b its issuance.also rtquirts On,applicant for such Permit M rile a signed summcnt
Eso thmhatsRcensedp...ot Me provisions Sq.FLFIoorArea Valuation
m H (commencing with Section 7000)of Division 3 of Ne Business and Pw2tsions Cole)or
y that he is emmpt thmefrom and the basis for Ne alleged eumption.Any violation of
Section 7031.5 by any applicant for a Recent,subjects the applicant to it civil Pendry of ane APN Number Occas Type
not mom Man fin hundreddollars(s5M Occupancy YP
0 1.as owner of the Property or my employees with wages as their sole compensation,
will do the work,and theswctum isnot intended or aQe,ed fertile(Sec.7 .Ban.
and Formula.Code:The Conwcmfa License Law alma tet apply to an..of of Required Inspections
property who builds or im pmva thereon,and who das suc h work himself or through his
own employees,provided Mutation improvements..at intended m oReread for We If.
however.the building or improvement is mid within as year of compledon.Ne owner-
builder will love the burden of proving Nat M did not build or improve for purpose of
sok.).
0 1,as owner of Ne Property,am uelmively contracting with licensed contractors to
ec utmct the project(Sec 7044,Bvincas and Professions Cade:)The Contractor's Li-
cove raw Boca nm apply to an owner of property who builds or improves thereon,and,
who convects for such projeeta with a contrucmr(s)licensed pursuant no the Contractor's
Liceme Law.
O L am...,t under See ,B d P C for da40
rescan
ne Data
WORKERS COMPENSATION DECLARATION
I hereby isTi,m under penalty of Perjury as of the following declarations:
0 1 him and will maintain a Cutifiam of Consent to self-inure for wands Copper.
section.as providd fa by section 3700 of the labor Code.far alto pattern.of tic
work for which this permit is issued.
0 1 haw and will maintain workers Compensation htwa .as required by Section
3700of ate labor Code,for the Performance of tk work for which Nu permit is issued.
My WorkeYs Compensation Wurana cornier and Policy number ere:
tamer: Sell6 6014PolicyNo.: "?4 001 : 1f
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(named.Aad ret bo cumploed if the permit is for.hundred autos(SIM)
or less)
I wafy amt in Ne perfamance of the work for which this Permit is issued.L shall net
employ any Paten in any cancer in as to become subject to site Workeri Compensation
Laws of California.Data -
Applicant
NOTICE TO APPLICANT:IL snor making Nis Certificate of Eacmption,you should
become subject to the Wends Compcnssdan provisions of Ne tabor Cade,you mine
.J O fordtwiM comply with each provisions or this permit shill W deemed revoked.
N CONSTRUCTION LENDING AGENCY
F1 hereby affirm Nat Main is a construction lending agency for ate performance:of
a t7 the work(ser which this Permit is issued(Sec.3097,Civ,C.)
QLender's Name0.
-
ZD z Undoes Address
O Q 1 certify d u 1 have mad his application and,tato Net Ne shove information is
VL Pcorrect.l lira to comply with N city and county ordinances and sum laws wluing to
DU building construtian.and hereby Authorise repmmoseliveserr this city m enter upon the
[21 shove-recntiuned property for inspection pu,pams
(We)agree to eve,indemnify and keep harmless the City of Cupertino against
CA liabilitiea,judgerma,cess end expenses which may in any my acmtm against mid City
U Z in commitments of the Scanting of this Permit. /,�! q
^' APPLICANT UNDERST D$$$AND WILL COMPLY WITH ALL NON-POINT Issued by: Date z — ` -f
SOURCE REGULATION
6�z?,uf�m Re
HA -roofs
Stgnuure of Appltn
HAZARDOUS MATERIALS DISCLOSURE Type Of Roof
Will ft applicant aforum building occupant stem m handleth Health amamil
material
u defined by the Cupertino Municipal Code.Chapter 9.13.cosi the ciland Sdcly -
ade.Scetianzss3zG)7 All roofs shall be inspected prior to any roofing material being installed.
❑Ya No
W II dm applicant or luturt Wilding occupant um equipment or devices which If a roof is installed without first obtaining an inspection,I agree to remove
emit
District? mat iair contaminants as dc0ned by the Bay Ams Air Quality Management all new materials for inspection.
DYa Ko
I have mad the haardoue from ils meramovnuunder Chapter6.95oftheCalifor-
wHalth&SalmyCode.Sections23505.25533 Sul 25534.ltudcnu,d thstiftW Wilding
dna tet curently low a to L that It u my,rspavilditY m wdfy dm aecupant of the
rtquirtmcns which masa m/yYpoor tmnanmoracenirmacoracupany Signature of Applicant Date
?� Cpl All roof coverings to be Class'W'Owner orauthomt0 agcm Dam' g or better