04020132 I CITY OF CUPERTINO '4�
BUILDING DIVISION PERMIT 4n CQNPRACT0AJNFURM�AT70N:
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BUILDING ADDRESS: K' S CONSTRUCTION """'04020132 I, n53n aTTTC!GTn C)TTS nn
�OWNERS NAME: PERMIT ISSUE DATE
�_VENVATRRA & VRNTT(,n PAT, QTT P n Rnx '7r Qj1i
SANITARY Nis, 'tOIJ'FROL NO.
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ARCHITECTAINGINEER: BUILDING PERMR INFO
BLDO ELECT PLUMB MECH
LICENSED CONTRACTOR'S DECLARATION -
1 Mrcby affirm Ian 1 me IicemW under prowdons of Chapter 9(commencing Job Description
with Sabo 7 )of Divadon]of the BUUnwaM Profedom Cove,and mylicenmh
infullfoj, 2R �3
5�z Dto, cl ✓uc.a 6440 3 BATHROOM REMODEL/REPIPE
all Da, Conlrscur i<•t(JU 1C1,✓aA b
ARCHnE LARAfi10�1
1�*Lxxnd my Nwls a pualic rtcnrda
=van I sw m her
O EWER BOIIDER DECLARATION
I 1 briefly affirm Net I am emmpT from the Contractors Licence Lew for IM
i
.0 removing rtamn.(Section 71313,Busimas and Profession;Cade:My city in cmmy
.13 9 which roqulwa a Permit in convect,alter,harpoon.Eemol W,in actual try structure C 7 o n n n
i- prim to its Woman.also requires the applicant for such permit in file a signed smarm _
Oat he is licensed purmant to tae prvisiana of the canuecmr;Lance Law(Chapter 9 Sq. Ft. Floor Area ValUlitiOn_ _
,xC$ (commencing with Saban 7000)of Division 3 little Bmwolood Professors Cade)or
3
that he In exempt Bxaefmm and the basis far the alleged eumption.Any violation of
Section 703 LS by any applicant for a permit subjects tM applicant in a civil penally of 3 2�a7�`b3lr er0 0 Occupancy Type
not seam man five hundmd dollars(9500).
❑Lot ownerafthe property,ormycenployces with wagedas lhelrmle ampewYon,
will do the work.and thesauetu e is not handed orartered fertile(Sm.7044,Busi.
and Professions Cade:The Contractor,Liave Law cars not apply in an owner of 1 Required Inspections
progeny who builds m improma thereon.and who loos such work himml f or through his
own employee,provided mu such improvements art not inuma ll moffered fprslle If, - -
however.the Wilding or improvement is old withm am year of cempletion,the owner.
builder will low the burden of proving was M did ant held or improve for purpose of
uleJ.
❑h u owner of the property,am exclusively contracting with Ilcemed conoumn to
construct the project(Sec.70".Bottom and Perfusiamn Cade:)The Contruurs Li.
cenm Law does not apply to an owner of property who builds or Improved thereon,and
who contracts for such pmjeca with a eantrscroKO licensed pursuant to the Contractors
Lima.Law.
I am exempt under See. .B k P C froths.
Owner Dam
WORKER'S COMPENSATION DECLARATION
1 thereby slDarmm under penally of perju7 aro of we following dalandorvc
❑Iban and ice farbya on337M ofGmenua mlFhuurthe WOrrmaCompcm
worn,r provided Oil for permit Section 3]00 of the labor Cade,for the performance of the
work far which this penned is island. alY/
❑1 have and will maintain Workers Compensation Trautman.as acquired by Section
3700af we Labor Code,for me performance of the work forwhich mil permit iNuoed.
My Worker,Computational Insurance c nler and Policy number are:
hi edict Nn
IFIhA713 OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(Tbhsanla al not McmnpLe,d Lima permit is foram handled dollars(SIM)
ar list.)
1 craft that in the performance of the work for which this Permit is Island.I shall not
employ enY pmmn'a anngrymufN MC ewb,ecl to the WOrke San pn--
Laaw�soufgCtWfhmN. i J_Lf�--`__I� —o..JCT a�( ,f�
N IO,SIL7E PL Ai ,Centimes,of Exemption,you should --- --
be sun subject in the Worker's Compensation previsions of f Liver Code,you mast
.J O forthwith comply with such provlslota or this permit shall he deemed revoked.
y CONSTRUCTION LENDING AGENCY c
(.w IMwbY,Rusetnmart isa construction Lending agency lot the Perfuammceuf
C' ti,work for which this permit h Wood(San.3097,Ch,C.)
Igl A Lenders Nam-
C1 Z Leader,Add,
Q Q 1 cenifY that 1 haw read this application and sum that the above information is
l4 t'" comae I agree to comply with all city and county ordinance and sum laws mining to
C)rV' building convection,and hereby authadm mpmeamaiwa of this city to enter upon Yu
Liz above-nomiloned property for inspection purposes.
C (We)agree he Su mil of this and keep homeless ti,City of Cupertino against
Liabilities,judgments,costs and expenses which may In my way same age Wt mid City
U,'� in consequence of the UNDERSTANDS of this permit.
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT Issued by: Dale
SOURCE REGULATIONS,
z�ltf�o4 —Q
sranm ATERIA S DISCLOS?I(e bum Type of Roof I
✓ Will tic applicant orfutum building occupant slow in handle huaacaus material
u defined by tho Cupertino Municipal Code.Chapter 9.12.and the Health and Safety
4i'amoodkox.OYe Nu zss]z(a25532(a)9.us Y All roofs shall be inspected prior to any roofing material being installed.
Will the applicant or follow building occupant use equipment or devices which If a roof is installed without first obtaining an inspection,I agree to re moe ve tits mr umimnu u deRncd by the Bay Awns Air Quality Management all new materials for inspection.
Duadct7 tit///
C3 Yes /p No
I have mao the hvardousmweriahmgmwmcnts underChap,r AY3 of the Glifor
mix Hu lth&SafcmYCadc,SaUamz3505,35533e n574 IundcmanA tMtifYe building
Joel not curmnoy Mw a unit.Yet It u mY wspotaihlitY m notify Y,meuPmt of ore
requirements which must be sect pna,m isluance of a Cc�flea,of Occupanry
� ���` \ t/ Signature of Applicant Date
Owncr6,yrZ9_e .gent ��� ` / bat. ' All roof coverings to be Class"B"or better