04050154 CITY OF CUPERTINO
BUILDING DIVISION PERMIT
x3<-CONTRACTOR INFORMATION IR
i _lw4hi-. .a*. s ,� "xors+ rT usg�, yx
BUILDING ADDRESS: PERMIT NOD 4 0 50 154
,401 CA2TTNF AV
:R'S NAME: PERM1IIT ISSUE DATE
CATHERINE & MAR
1 „E: SANITARY NO. CONTROL NO.
ARCHITEC(ENGINEER: BUILDING PERMIT INFO
BLDGELECp PLUMB MECH
0 0 0 0
uoo LICENSED CONTRACTOR'S DECLARATION
e 1 hereby afnrm Our I An ranted ander Provisions ofchapter 9(ammeneiag Job Description
in wisello=TOlMpeDivision3of the BuainrssmO Profcssiom Code.endmylicenmis
tris rarer and erfn. REMOEL— —INTERIOR
nj3Z License Class Lin.N �,
—p Dau C'S DECLARATION
F'�'
ARCHITECT'S DECLARATION
s c U 1 undcrsunJ my plans shall he useJ u public recnNs
a.
l VA
Licensed Professional E
OWNER-BUILDER DECLARATION �I
3 i E
H1 hereby atnrre maar I am exempt from dm Conuecrors License law for the aid J
moo following mason.(Sccuo ](131.5,Business and Pmfessiom Code:Any city o,county /0A�
K$ff which inquires A permit It Construct.him,.improm
ve,demolish,or.,At,any nrucume Q
nnn
_xiprior to its rq
issuance.nor ruims the applicant for such permit o file a signed statements that he is licensed pursuant m the provisions of the Conlracmri Llanm Law(Cha
(cprer9 Sq. F[. Floor Area � ��alUBI70❑
=
xl-$
(commencing with Section 70raq of Division 3 of me Business and Professions Code)or
ne _ At he Is exempt merafrom and me basis for me alleged exemption.Any violation of
Section 7031.5 by any applicantfar a permit subjects the applicant to a civil penalty of 3MNNhffiber00 Oc'cupancy Type
not more Nan five handrail dollars($500).
0 1,as owner of the property,or my employers with wages As their role compensation,
will do Ne work and the•wctura is not imendcd or offered forsak(Sce.101a,Business
and Pmfcsdohs Code:The Comment's License law does not Apply to An Owner of Required Inspections
property who builds or impraves Nemon,and who does such work himself or Brough his
awn employees.provided that such impronments are notimended aro@rod inside.It.
however,the building or'mPMWman,is mid within one year of completion,the owner
Wilder will have the Women of proving that W did not build w improve for purpose of
sale.).
1L.-ed
.u owner of the property,am reclusively contracting with licensed contractors to
von the project(Sec.7(144,Business and Professions Code:)M Comweror's Li.
cense taw dors not apply to an owner of property who builds or improves thereon,and.
whocomucas forace aconwcror(s)limnwdpursuan,m Bm Conuactoes
License
❑lam ac pt undo Sa. .Bk PCfr
LW nefor"
Data 5f 2
WORKER'S COMPENSATION DECLARATIO
rcby affirm under penalty of perjury arc of rise f mg decla,nions:
0 1 have and will mannish a Cerrifiau of Coruemt mself-insure fw Worker'sCompen-
workf ss hick this
fpr ni Section dToO of the labor Code,far Ihe perfo,mance of Ihe
work for which this permit is issued.
❑1 ban and will maintain worker's Compensation Insurance,As mqumed by Section
3T00 of the Labor Cook.far Ne penfarmmce of Ne wart for which this Permit is issued.
My Workers Compensation Insurance artier and Policy number Am:
Caricr. Policy No.: _
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
mots section need not he complemd irthe permit is fwane hundred dollars(1100)
or leseJ
I Certify that in Nc Performance of the work for which this Permit is issued.I Mall not
employ any person in my mmnerm As to become object to the Workers'Compensation
Laws of California.Dau
Applies., t
NOTICE TO APPLICANT:IL after making this Ccmficam of Excmt you should
become subject in the Worker's Compensation provisions of the labor Code,you miser
.JZ forthwith comply with such InOwnms or Nu permit shall he domed nevoted.
Z O CONSTRUCTION LENDING AGENCY
1-rZ IWrebyaRrm Our Bcrc iso Construction lending agency I.,the ra,homanauf
7.> Ne work for which this permit is issued(Sw.3091,Civ.C.)
0 Lenders Nam.
U Z Lenders Add.
U C) I certify that 1 hive read this application and suis Nat the above information is
U4 F Correct I agree to comply with all city and county Animators and sum lava mlating to
0U building contraction,and hereby authome representatives of Nis City to enter upon the
} W above-mentioned property for inspection purposes.
F' 4' Iimilitiea judgments.ree to costs and exnifyend„eh may any waysrs me ee=aof gainst saiino d City
ti penarsw yi ya gain y
U Z in consequence of to Br of Nis permit.
.. AP CAM UNDEF AN AND WILL COMPLY WITH ALL NON-POINT Issued by:S4�4 Date i
50 E REGU TIO S.
�S 'Z Re-roofs
no mof APPlican✓ nlraeon Date
HAZARDOUS MATERIALS DISCLOSURE Type of Roof
Will the apli icam air ran.building occupant store or handle hacarelmn meurial
defined by the Cupertino Municipal Code.Chapter 9.12,and the Health and Safety
de,Section 2553z(a)+ All roofs shall he inspected prior to any roofing material being installed.
Will the applicant or future building=open,use equipment or devices which If a roof is installed without first obtaining an inspection,I agree to remove
emit hazardous air contaminants As defined by Oc Bay Area Air Quality Management all new materials for inspection.
District?
[:1 Yes �*u
Ihave mal theh uurialsmquimments under Chepurb.95ofNeCalifor-
So.,
odc,Scctions NI"""md25534.1un@rsund thaifthc building
ha mnanr it is my maponsihility m nary Bs cecupml of Nc
A.
^ranaoracnaineam.raaap.nyy. )S' nature of Applicant Date
ascot ✓Darn / (/� All roof coverings to be Class "B"or better