04100180 CITY OF CUPERTINO ,t•&77., #:a 77 ^'. """ "'dE W;
BUILDING DIVISION PERMIT 6,UNCRA ORAN'PI,RM�ATIUW5,
am1.DINO ADDRESS: , - R.J. PEREZ CONST INC PERMIT"414100180
NET' AME: PERMIT ISSUE DATE
E: SANITARY NO. CONTROL NO,
(408) 252-2797
ARCHITECTIENGINEEK: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
] o l� o
+LOQ LICENSED CONTRACTOR'S DECLARATION '
1 homey film that 1 am licensed under provisions of Chapter 9(commencing Job Description
whh Scetlon 7M)of Division 3 often Businen rose Professions Code.and my license is
Licene Class RecL SFDWL-2 STORY (4667 LIVING)
3 Z License t Clan Lie.R
g Date Convector GARAGE 829 SQ. FT. ff p /� [[[��� (�
r As"Ibeuse DECLARATION iltt II A/� �rt___
U i understand my place+hail ha used u public record+ Qvk`gt�(S�`\H '1.rla"'
reed�a Licensed Profeuionel
3 OWNER-BUILDER DECLARATION AUGS 1 hereby eiirm that I am exempt from Lha Conuacmh License law for the G V 2006
I:!-D following mann.(Swdan 703 1.5,Buslrua and Prole in.Cade:Any city or county -
+� which requires a perm(to construct altar.Improve,demolish,or repair any strackre
prior to its issuance.also requires din applicant for such permit to fit a signed mournat
FE<
that he isllecosedpursuant to the provisions ofdue Contractor's License Law(Chapter 9 Sq. Ft. Floor Arear goP280
Sg manumncing with Section 7000)N Division 3 of the Buslms and Profession Code)or
IIIICCCC that he Is exempt themfrmn and the basis for the alleged assumption.My Wolauon of
Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of APN Number Occupancy s31
not mom dun ane
Bve hundred doll. P y ),pe
❑I,uowrurarthe prolws7Y.car my moPloyces with wgeaactitav sok eampensetion. 35601053 . 00
willdo the wart,and Neawctare Or not Intended craffered formic(Sec.7044,Bailouts
and Profess on,Code:The ComraMr's L earrem Law does w1 appy to an owner of Required Inspections
property who builds or Ireproven thesean,and who does such wait himself or through his
awnemployeG.provided that such improvements are not immodest monarM forule.If.
however,the building or Improvement is sold within aro year of completion,the owner-
Wild"will have the burden of proving that he did not build or improve for purpose of _
sato.).
Ulf a awrcr of the pmpeny,am exclusively contracting with licensed cenaacton to
construct the project(Sec.7044,Business and Prefesslons Code:)The Comncmr's LI-
mum law does not apply to an arxner of property who Wilds or improves contrast.and
ocontracts for such projects with acommetons)licensed P.1 to tho Conuanoh
rare
Law.
Ll{I n GemptusndGSee .Bh PCforsemmoon
nor ' o p � Date e '2 r -
WORKER'S COMPENSATION DECLARATION
1 hamby afTm under pnWly of perjury oro of tita following declarations:
I Mw and will meinuin•Certificate se
ofConnt to selRimum for WorkeM1Campw- _
ad.,as provided for by Section 3700 of the Labor Code,for the performance of the
wart for which duh permit is Issued.
0 1 have and will maintain Worker's Compensadon Insurance.a required by Section
3700 of the labor Cade for on,pRormawe of the wort for which this permit Is issued.
My Workees Compensative insurance canner and Polity number art:
Carrier: Policy No.:
CERTIFICATE OF EXEMPTION FROM WORKERS
COMPENSATION INSURANCE
(This smion rued Out becompleted HOW permit is Imam hundred dollars(SlalO
or Was)
I unify that in the performance of the work fa which this permit is Issued,I NW ria
employ any person in any manroran u he became subject to the WOrker'COMPeasOan
4w of California.Data
Applicant
NOTICE TO APPLICANT:If.after making this CeniOnto of Exemption.you should
become subject to the Worker's Campnaation provisions of W Labor Coda you must
.JO forthwith comply with such provisions G NV permit"I Is,darted revoked.
,zr CONSTRUCTION LENDING AGENCY
PW
I hereby affirm that then is acousuucuon lending agency for the performance or
IY> the wmt far which this permit v iured(See.3097,Civ.C.)
14 Q Lattices Name
z Landees AOdrea
U O 1 certify that I has mad this application and sure dust the&Wve information is
LL^ sources.I agra to comply with all city and worry ordirwKxa and sum laws relating to
tr.'J Wilding convection,and hereby authonm representatives of this city to caner upon the
fJl move-mentioned property for inspection purposes
FCy^a (We)agree in ave,indemnify and keep harmlrss the City of Cupertino against
o-y h IlabllluG,judgmenu.eosumdexpenseswWchmaylnanyv yaccmeagalnstuid CityIn p� C���
U
APPLICANTeof the UNDERSTANDS AND this
WILLWILL COMPLY WITH ALL NON-POINT Issued by: Date 2 " -Cb
SOURCE..A OYA ONS. /�/�
—� �a 1 Re-roofs
Signsturc of AppliesAZARDO Data
HAZARDOUS MATERIALS DISCLOSURE Type of Roof
Will the applicant or
refotum Wilding OccupantChapter
stare or harWle Health
mammal '
u deaned by the Cupeniw Municipal Code.Chapte
r 9.11,and din end Safety
-LrIde.S❑Yescdon 25531(a)7 All roofs shall be inspected prior to any roofing material being installed.
yfna
FWill the applicant or future building Occupant um equipment or devices which If a roof is installed without first obtaining an inspection,I agree to remove
it hammnua air cwuminanu G derecd by the Bay Amo Air Quality Management all new materials for inspection.
District?
0 Yes Erro
I have read the haaNnusmatadds mquiremcnu underChaptar S93 ofthe Califao
tie HealthBSafety Coda,Secuomi3N15,25533md25534.1unde�d Nulfthe building
does not currently have a tenant that It h my responsibility to notify the occupant of the
rcyulremcnu whkly must W met poor to Issuance oras Certificate of 0", Signature of Applicant Date
v {L
S All roof coverings to be Class"B"or better
Owner car authorized agent Dam