04050073 CITY OF CUPERTINO `-' a e u•kr �' "' '
BUILDING DIVISION PER" CONTRA.CT094INF'OR 'r
BUILDING ADDRESS: SAMUEL CONSTRUCTION PERMIT"°04'050073
OWNER'S NAME: PERMIT ISSUB DATE
SUNNYVIEW LUTHAREN HOME 1427 PT,QRAVTqTA A177 _'
NE: SANITARY NO. CONTROL NO.
408 249-2 82 8
ARCHITECT/ENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
p
yap LICENSED CONTRACTOR'S DECLARATION
x I bcmby of@m that 1 am licensed under provisions of Chapter 9(commencing Job Description
n< with Secila ]gIU)ofDivislaa3of the Business and Tessipnu Code.aM myliccasela
<�z IFuR,"d`1 t' L .g 772 TI--OPENING Q LIBRARY
can A
qARCHn he sesta DEr
22 1s,dcrwnJ my Pines shall he u .,uspuMk ATION
3Q Licensed Profcainnal /a
s20 y OWNER-BUILDER DECLARsion, ± �� �� j
aa''TT_11 1 QA
1 hereby affirm that I am exempt from the Contractor's License law for the (///'/ ftp
D O which ng masoa.Permit
t RDLm r.altar.
and are.dem ro h,or Code: er itym or county 1�
which reyuira•permit to cnnwucL alar,Improve.demolish,or repNr any swcture �� ,
F.� prior in its issuance.also regaims the applicant fnrsach Permit to file a Signed Stuarrent ,
that he is licensed pursuant to the pmvisiom of the Commerce's License Law(Chapter 9 Sq , t. Floor teaI aluatl'n
$ (commencing with Section 7")of Division 3 of the Business and Professions Cak)or /p !
that he u exempt therefrom and the basis for Bre alleged exemption.Any violation of / n
Section 7031.5 by any applicant for a permit subjects use applicant to a civil penalty of 3 2 `�Jll et0 n '- c � ' f pe
not mom than 0w hundred dollars(3500). -
I,u owner of the property,or my employees with wage a their sola eampeasadon,
will do the work,and the structure isnot intended or offered for ale(Sec.7044,Business
and Professions Code:The Coapacor's Liame Law daces sot apply In an owes,of Required Inspections
property who builds or improves thereon.and who does such wark himself or through his
awn employees,provided retrench improvements are not Intended proffered fmsak.if.
however,the building or improvement is sold within one year of completion,de oven,
Wilder will have Ne burden of Proving Nat he did not build or Improve for purpose of
sale.).
❑1,u awmr of the property,am exclusively contracting whIl limned omenta,,to
construct the pmject(Sec.70td,Business and Professions Code:)The Comiracrar's Li.
cans,law does not apply in an owner of property who builds or improves(hereon.and
who con were for such projects with arnnuemri licensed pursuant in the CostramoY,
License Law.
❑Ismaaempunder Sec. ,B&PCforthi,maon
Owner Date
WORKER'S COMPENSATION DECLARATION
1 hereby of ren under penalty of perjury arc of the following declentipns:
haw and will maWinn a CeNOateof Covent m self-insure fa Worker's Compcn.
tion.as provided for by Section 3700 of the labor Cade,for the performance of the
work for which this permit is issued.
❑1 have and will maintain Worker's Compema0on Insurance,as required by Section
3700 of the labor Code.for the performance of the work for which this permit is bound.
My Workers Compensation Insurance artier and Policy number am:
p
Cartier. :'a-7c Policy No.: ?c
o t 1 3
CERTIFICATE OF EKEMPIION ORKERS
COMPENSATION(NSU NCE
Ends=,I.mod nm becampleted Ifthe permit I,farane hundred dollars(SIM) '
orbssJ
I cenify that in the performance of the work for which this permit is issued.I shall not
employ any person in any manner an as Is became subject to the Workeri Compensation
Laws of Celifionid Date
Applicant
NOTICE TO APPLICANT:IL afar making this Cemlicak of Exemption.you should
become subject to the Worker's Compensation previsions of the IAWr Coda,you must
.JO foMwiN comply with such providov or this permit shall be deemed revoked.
zy CONSTRUCTION LENDING AGENCY
Fw (hereby affirm the them is a construction lending agency for Ne serf ormance.f
C 7 the work for which this Permit ts issued(Sec.3(1 Civ.C.)
QLender's Name
Lemino' Add.
U0 I ceNfy that 1 have rod thla application orb sue that the aWw information 1,
(y E cmmct.I agreIt
ear,to comply with all city and county onlinames and laws Miming to
p CSJ' building convection,and hereby apNmier rtpreunutiws of INS city to cnur upon see
W abovc-mentionnd property for inspection purposes
LL (We)agree in sew,indemnify and keep harmless the City of Cupcnino against
r V3 liabilities,Judgments.costs d,s,.which may in any my accrue against said City
V z in�9aonnse,uence of the granting of this pctmiL
t--t APRLIQANT UNDERSTANDS AND WILL COMPLY W6fFALL NON-POINT Issued by; Date
SOURa REGULATIONS. o ��
U .a Re-roofs
slgnaumpp ca`✓ eaR4I55 MATERIALS DISCLOSURE rdin Type of Roof
Will the applicant or forum Wilding Occupant sham in handle ha ommus material
as defined by the Cupertino Municipal Code,Chapter 9.13.and the Health and Safety
Code.Section 23332(e)7
❑Yas PNu All roofs shall he inspected prior to any roofing material being installed.
Will the applicant or forum building Occupant use equipment or devices which If a roof is installed without first obtaining an inspection,I agree to remove
t havArom s air a useemantr a danvd by the Bay Ace Air Quality Management all new materials for inspection.
aricG
❑Ya C(No
I have read the hasNnus materials requirements underChapter6.95 of the Califon
nu Health&Safety Codc,Sadoas25505,35533 and2553s.I undeound(half ilk Wilding
Joes trot entrant y hand a knant,the it is my,¢span bilhy to notify dee occupant of ilk
reyulrtmcnu kh uab0our prior wuse anpcoIsccniBcamofOccu ay. Signature of Applicant Date
� SA wt Lc�L \ S 7r t 4 All roof coverings to be Class"B" or better
Owner or amhorired eget Dau