05060162CITY OF CUPERTINO
„s•y s&w "-x ass �.' r �',afie'''e n 'Ici
BUILDING DIVISION pERjyjl'r.CONTRAC�'ORIN
OiATION -
*.a.rR:et'Sa .:f3ii'Lb. „r _a•,,. / a"ae' %s�TM'yc,'
BUILDING ADDRESS:
PERMIT NO. 05060162.
360 R ESTATES DR
ER'S NAME:
PERMIT ISSUE DATE
SA4MY MOK
01/03/2006
NE:
SANITARY NO. CONTROL NO.
ARCHITECr(ENGINEER:
BUILDING PERMIT INFO
BLDO ELECT UM MECH
PLIC
G� O O
LICENSED CONTRACTORS DECLARATION
Job Description
I homey eri m that 1 Am licensed under PPO WOM of Chapter 9 (mmmrncink
with Section 7IX10) of Division 3 of the Business and Profession Code, and my Hearst, is
imm�mreeenderfan.
-Lk.0
ADD 1268' -LIV. & REMODEL 30621
License Clue
Data Comrsather
ARCHITECT'S DECLARATION
I understand my plantshell he used as public meet&
,
Licensed Pnsfeui... I
OWNER -BUILDER DECLARATION
1 hereby affirm that 1 am exempt from the Conlcanoei License law for the
following mason. (Section 7031.5, Business and Profess unt Cole: My city or county
which requires A permit to coutomi, alter, improve, demolish. or repair any structure
Wpm $200000
prior m its Worthen. also rectum the applicant fnranch Permit to fic signed statement
thetho is licensed pursuant W the provisions ofthe Commerce, liar Law (Chapter 9
Sq. Ft. Floor Are Valuation
(commencing with Section 700M of Division 3 of the Busimuand Professions Coe) or
that he is exempt therefrom and the buts for the alleged Assumption. Any viohtian of
r
Section 7031.5 by any applicant for a permit ubjeeu the applicant to a civil penalty of
7
!'. Occupancy `] pe
h
Trot mom than five hundred dollars (f500),
❑ L u owner of the pmpeny. m my employes with wags u Weir ole mmpeoudon,
willdo Ne.,L.dNeavenumism,immndeduoRemdfmsele(See.70 .BuvmeaI
_®
And Professions Code: IT. Contractor's License Lew does not apply W an owns of
d
U1
property who build, or Improves thereon, and who does such work himself or through his
gsKty+rJ;
own employees, provided that such improvements Am not Intended uoffemd for are If.
however, the building or improvement la told within ane Xu of completion. the owner
builder will have the burden of proving that he did not Wild or improve for purpose of
sem.).
[V. As Owner of We property, am exclusively convening with Iimmsed con"cWrs W
convect the Project (Sec. 7044, Business and Profusions, Code:) The Comischor4 U.
came law does not apply to an owner of property who Wilds or Improve linemen. ad,
who contracts for such projects with a conuacmrre licenced pursuant W the Cormuster's
.
License Law.
Q l am exempt under See B&PC fu this moon
4'/— i' Dem
O6
N'SdKER'S COMPENSATION DECLARATION
OF
,
1 hereby affirm under penalty or perjury one or Also following declNvou:
❑ I haw and will maintain aCenlfrcamofCOnstnt W self -Inure for Worker's Compen-
-
cation, As pmvlded for by Section 3700 of the Inbar Code. for the performance of the
woh for which this permit is Issued.
_
❑ 1 baro and will maintain Wacker' Compensation Insurance, As required by Section
3700 of the labor Code, for the performance of the work fu which this permit is loved.
My Wukcea Compevadnn Insurance carrier and Policy number Am:
Cartier: Policy No.: _
CERTIFICATE OF EKEM MON FROM WORKERS'
' COMPENSATION INSURANCE
ablasecdon coed nothecoopleted Hthe permit U formucl uadmd dollars ($IW)
u ice)
1 coolly that in the performaneo of the work for which ibis Permit is issued, I shell not
employ any person in any manurm As m become subject to rho Worken'COmpen m
Law. of Califomp. Dam O/— os,— ��
Applicant ie
NOTICE TO APPLICANT: If, after making this CeniOcate of FacmPtion, you should
become subject W the Workers Compensation provisional of the LAW Code, you most
forthwith comply with such prevision or this permit shall W deemed! revoked.
CONSTRUCTION LENDING AGENCY
1 hereby affirm that Wert Is a connotation lending agency for the perfummm of
than work for which this permit Is Wend (Sea 3097. Civ. C.)
Lender's Name
'
Lender's Addis••
1 cently that I have read Wb Application and ea m that the above Information N
correct 1 agree W comply with all city and county ordinances end tum laws mining W
Wilding construction. and hereby authorim representatives or this city W enter upon the
aWw-mentioned property for Inspection purposes
(We) agree to taw. Indemnify and keep hatmleas the City of Cupenuo against
liabilities, judgments, cuss And expenses which may In any way some, against said City
in consequence of the granting of this permit.
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON -POINT
/
Issued by: Date
SOURCE REGULATIONS.
k'Re-roofs tic
Type of Roof
Signuurc pplicanaConRData
HAZARDOUS MATERIALS DISCLOSURE
W911 We Applicant or forum Wilding occupant eWm "handle material
u tle0Sed Health
the Cupertino Municipal Code. Chapter 9.11, and Ore Health and Safely
Section ss531(.)7
Section
All roofs shall be inspected to any roofing material being installed.
❑ res a
prior
If a roof is installed without first obtaining an inspection, I agree to remove
Will the applicant or future Wilding amupam ase equipment art devices which
'
It havudnu air conuminanu As defrud by the Bay Arm Air Quality Management
all new materials for inspection.
District]
❑Yes .zjlo -
,
1 haw mad the hundma materials requirements under Chapter 6.93 ofthe Califor.
nia Health & S4rctyCodc, Sections 15503,13333 the 25534,1 undcrmnd Wulf the Wilding
data mol currently have • anan u it Is my respectability W notify the oecupanl of dm
mgWmrmals"ich mu at prior lm issvanm of, ecninamar Occupancy.
Signature Of Applicant Date
z ,_—� -ry o
All roof coverings to be Class "B" or better (_
owner tarived&Care
un Dam