04080214 CITY OF COPERTINO
BUILDING DIVISION PERMIT CONTRA.CTORINFORMATION `-:
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BUILDING ADDRESS: TOENISKOETTER & BREEDING I FCgMITND04080214
OWNER'S NAME: PERMIT LSUEDATE
CHINE
L:
SANITARY 0. CONTROL NO.
ARCHITECT/ENGINEER: BUILDING PERMIT INFO
BLDGEIECr PLUMB MECH
0 E 0 0
=00 LICENSED CONTRACTOR'S DECLARATION
m I thereby affirm Nat I are licenser under provisions of Chapter 9(commencing Job Description
Z� with smile 7M))of Division S of the Bus—arM Professions Code.and my license is
^toy in fu fo nd edea ✓- REVISION--CEILING DETAIL 5 7 8
p�z License Class Lic.R a s
'�� D� ARCIUE =LXRATION NO NEW PERMIT ISSUED/ORIG. #04040178
li w I understand my plans shall he public records
J'r
Licensed Professional
5 OWNER-BUILDER DECLARATION
P 1 hereby affirm that 1 am exempt from the Contractor's License Law Our the
00 following reason.(section 7001.5.Business and Profession Code:Any city or county
$ which requires a Permit to moslruct,alter,improve,demolish,or repair any structure
poor to its issuance.also requires the applicant for such Permit to Glc a signed Statemcnl
Y G Nat he islicenuJPunuanuothePmvivonsnflheConuacmr'sLimnseltaw(ChaPlrsY Sq.Ft.Floor Area Valuation$32
m�$ (commencing with Section 7000)of Division 3 orthe Business and Pm(casiow CMe)or
that M is exempt themfrom and the basis for the alleged exemption.My violation of
Section 7031.5 by arry applicant for a permit subjects she applicant to a civil penalty of APN Number Occupancy Type
not mom Nan Fin hundred dollars(5500). P Y YP
wi I,u owror of the the structure
re is omployca with wages u their sole7044,Business sstion,
32633102 . 00
will dothework endo: stmetumisnotinawedorowsed Tarsale(Sec.7014,ownero
and Professions Cede:The Contractor's hemes,Ldwho Law anew not apply ff an owner of Required Inspections
own ery who Wiprovided Oats themes,andwht tau such work h roffir or trough his
however.the u, inori pr mchimps vements mid within ne year oedwoeered for owneIf.
- A
however,Ne building or ire of pmenl is std within one year of completion.Ne owner-
buitder will have to burden of proving Nat he did MI build w improve for purpose of O
ale.). n
L nm owner of ct Sec.7property.am exclusivelyand
canmeting with:)no d oontramors i. \�
nse La d esojot (Sec.Toa,Busowner
of and Prolusions Code:)The es then on, rad
cense Law dote not apply loan own.orpropany who
ce builds or improves thereon,and
who contracts for such projects with a eontrumKs)liceue0 puramm to tr Conwcmts
Lic no,Law.
I am exempt under Sec. ,`B&P C for this moon
-cr Date P'—.24--4%1
WORKER'S COMPENSATION OE ATION
I hemby affirm onderpamltY or perjury oro° following declarations:
.have and will maintain aCerdGateof Comem to self-insure fro Worker's Compcn-
sm on.as provided for by Section 37M of the Latour Code.for the perfmmatuz of the
work for which this Permit is issued.
1 have and will maintain Workers Compensation Insurance,as requited by Section
3700 of NC Labor Cod.,fro the perrwmanee cd the work for which this permit is issued.
My Workers Compensation Imuran¢carrier and Policy number are
a ' Policy No.: _
CERTIFICATE OF EXEMMONgROM WORKERS•
COMPENSATI ANCE
(7TissectiasmednolMcomplcte I permilis for one hundred dollasa(S 100)
or loss.)
I certify Nat in the Performance of the work for which this permit is issued,1 shall not
employ any Noun in any assents so as in become subject to the Workers'Compc tendon
Laws of Calif rrom Date
Applicant
NOTICE TO APPLICANT:If,after making this Certificate of Exemption,you should
become subject to the Worker's Compensation provisions of Ne lehw Cade,you mum
.J z forthwith comply with such provisions or this Permit shall be deemed revoked.
z O
h CONSTRUCTION LENDING AGENCY
C4 I for which his Nal them is a comwainn lending agency for the peKormance of
<Y Nc work rue which Nis permit is issued(Scc.3W7,Civ.c)
W�Q Isnder',Name
=z Lenders Add.
U Q 1 cenffy Nn I have tend this application and sate Nm the above infwmaton is
{I. F mmmL.I agree to comply with all city and county om immma and state laws relating to
C U building construction.and hereby authorise representatives of Nis city w enter upon the
W above-mentioned property for inspection purposes.
C. (We)agree m save,indemnify and keep harmless Ne City of Cupertino against
TTI in
of O.cot andcxp.nsa which may in any way acerae agumlatiOCity
Uz in consequence of Ne gnnting"f Nis Permit. 11 Q(7y
^ APPLICANT UNDERSTANDS AND WILL COMPLY W614 ALL NON-POINT Issued by: Date /
SOURC REGULA ONS.
Re-roofs
1p`6rAKfu,arVCmnftcl.r ate
HAZARDOUS MATERIALS DISCLO Type of Roof
Will the applicant or future building occupant store or handle huardous material
Fmull'-so
od by the CupertinoMunicipal Code.Chapter 9.12,and Ibe HcaIN and Safety
Yu Yeeton 2ss255320)? All roofs shall be inspected prior to any roofing material being installed.
1fNu
Will the applicant or future building occupant use equipment or devices which If a roof is installed without first obtaining an inspection,I agree to remove
hsI cam mous air contaminants as defined by the Bay Area Air Quality Management all new materials for inspection.
Yes Rr u
I have read Or huallommmerials requirements under Charoer6.95 of Nc cable-
nia Health&SafmyCwe,Sections 25505.25533 and 25534.1 understand Omifrhe building
Jost�ny�kfa^��dy haves a tens",Nat it u my responsibility m rawly the occupant or the
m I. l hichcot hmet Ponaoorac.rtira P Signature Of Applicant Date
ner
'G— All roof coverings to be Class "or better
owraub thorized agent $)� Date g 'B