05110095 CITY OF CUPERTINO
BUILDING DIVISION rAX6;T'OR INFOIWPA'
PERMIT TIOW�,
BUILDING ADDRESS: PERM117NO.05110095
R'S NAME:92'A'An XF.MnT.R. qT
PERMIT MUTE DATE
k HARTSH qARMA 12/22/2005
PHONE: SANITARY NO. CONTROL NO.
ARCHITEC1711INGUNEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB PASCH
Oz
0 LICENSED CONTRACTORS DECLARATION
MI washy Mm that I am licensed under provisions of Chapter 9(Commencing JobDescription PIA
with SWUM TICU) fDivIM.A 3 of due But.AM Prom ors Code.AM my license is Qr 4
,a fail farm and Affect.
Lk...Cl. U.. ADD 95 ' (KITCHEN) CONVERT HAL
Dam.Contractor TO FULL BATHROOM
ARCHITSCT*S DECLARATION y
y6 u.Ta I command my plans mall he used A,public remads
Licensed Professional �e4f
gO OWNER-BUILDER DECLARATION
TV 2 1 hereby AfflM that I A.exempt from the cmars.t.es License Low for the
E a following moon,(Secular 7031.5,Business And Profession Code:My city at county
which acquires a permit to construct,alter,improve denvollah.or repair any structure
VIA p4ftllk
^Z� Prior 10 HIS issuance,Alan requires Use Applicant forsuch Permit in rile a signed tialcoverat
that he is licensed personal to ft provision of Plan Contractor's License,Law(Chapter 9 Sq.Ft. Floor Area �00
(commencing With Scealm 7000)of Division 3 of the Ilmdremoul Professions Code)or
Net he is exempt Imminent and the Inands for ft alleged exemption.Any violation of
Section 7031.5 by my Applicant for a permit objects the applicant ho a civil penalty of APN Number Occupancy T�pte
not mom than five hundred dollars(fsooL
0 1,as owner of the prop",.my employ..with"So as their win compArsadear. 32613109 . 00
will de the work.and are opmemone 6 not Intended or offered for age(Sec.713,44.Bad�
And Poolloalons Code:The Commodes Lim.Lt.Mas Ads Apply to an owner of Required Inspections
property who build,or improves demon,and who does such work himself or through his
own employees.provided dust Patch improvements are an,boosted wollmed Per zdA.ff.
Monvo.has building w improvement is sold woman am year,ofmampletion.Use owner,
builder will have no leaders of proving dust An did not build w improve[a purpose of
1.As owner of des Property,am"Clutfively contracting wish licencenal Conusaom ta
ca,As Con a Plan,project(S.C.7044.Business ad Profusions I.Code:)The Contractors U.
mass Law does not apply as an owner of propenty,who builds or improm thereon,And.
who Common,for such preject.,with a commetor(s)licensed Manor to the Cantriamer's
License Law.
El I An,uavdarlw .B&Pcf.r this...
Dam la-
WORKER'S COMPENSATION DECLARATION
doby allarn under perafty at perjury am of the following declarations:
0 1 hsve and will maintain aCcallicancofCamserat to self-Insum fwWwkeesCompn.
attion,As provided for by SWUM 3700 of the Labor Codc,far the performum of IM
weals for which this permit Is iumd.
E]I have and will maintain Wettest's Compensation Insurance,a m4ained by Section
37M of the Labor Code,for the performance of the"Us for which this permit is ISAMU!.
My Worker's CMFAn3AdM Insurance carricr and Policy number am:
Cartier. Policy No.:
CERTIFICATE OF EXEMPTION FROM WORKERS'
. COMPENSATION INSURANCE
(71h6scellon wed malbecompleted little Permit Isfarame brandreddellar,(SIM)
ar low.)
I cadly,that in the Performance of UK work for which this pearrall is issued.I mail not
employ Any posse.on my man w0dams,Conspoessfic.
tawsca f I D In
Applicant
NOTICE TOAPP rANT.If.after making this Ocalficam of Exemption,you should
bannown subject us Um Worker's Compensation provisions of Pan Labor Code.you am
Z forthwith amplyM such provisions a,M.permit me]Pon deemednevardoed-
z 0
CONSTRUCTION LENDING AGENCY
E4 I hereby affirm that Men,I..connotation lending agency for the Performance of
> the mark her which this Permit Is banned(Sm.3(197,On,C.)
ELenders Name
d Lender's Addeo
I certify that I have mad this application and suac that the above information is
COMCL I agree P,Comply with all city and county ordinances and same laws relating in
DU building construction,and hereby authorise reprownwim of this city to enter upon the
W shove-mentioned property for inspection purposes.
CL (We)agree in As",indemnify and keep harmlem the City of Cupertino against
to) liabiliflea,judgmants,costs and expenses which may in any way occme against aid City
U 7
lAn.c;LIC NT MoccPINCERolductmSall a K.I.
DS AND WILL COMPLY WITH ALL NON-POINT
IR GUALATIO Issued by: Date
C so 'k,;Wi
/a Re-roofs
Si m a 0 epll.MCowrectarDam
HAZARDOUS
MATERIALS DISCLOSURE Type of Roof
Will ft applicant or future building occupant store arbandle Menelaus material
f1mud by the Cupertino Municipal Code,Chapter 9.12.and the Holds and Safety
SWUM 25532(.)7
[:]Y. All roofs shall be inspected prior to any roofing material being installed.
Will the applicant or future building occupant van,equipment Car devices whichIf a roof is installed without first obtaining an inspection,I agree to remove
It h-larm-1-it Cmusural...U As defined by me Bay Arm Ail Quality MAnIzernlrd all new materials for inspection.
District?
0 ye. ONu
I have mad Us:haloohlous materl.l.requirements am,Chapter 6.95 of the Calif.-
ni.Hmh1b&Sd.lyCo&,SDct1 25305.25533 runal 25534.1 undessmad the dean building
J..Current y - responsibility 0 notify Use oWupant of live
requite nohiclaw i=of a Carnificau,of Occupzr�, ignature of Applicant Date
hatus ior
A,I ��V`XUA, /,;�, p- All roof coverings to be Class"B"or better
2r authorized agent Dam br .