04090288 CITY OF CUPERTINO
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BUILDING DI VIS ION PERM !ONTR'ACTOR I11 ,NFORM aN�
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BUILDING ADDRESS: PERMIT NO04090288
21203 ORO nT
OWNER'S NAME: PERMITIESUEDATE
_ MICHAEL & HILDE ROME
i SANITARY NO. CONTROL N0.
E:
ARCHf1ECT/ENGINEF3U
BUILDING PERMIT INFO
BLDG ELECT PLUMB MECN
0 0 0 0
u00 LICENSED CONTRACOWS DECLARATION Job Description
C 1 hereby affirm Our I am licensed y do{provisions of Chapter 9(commencing - — - _
b with cno u0U) fDivision3adw Husiilragand Profcuinns Code,and my license is
in f°' °e a / q BATHROOM REMODEL (2)
'q_ Doenmeam LK.�L1�/u S CONTRACTOR: W. EARL THOMAS GENERAL CONTRACTOR
H Dam _Commcmr
`qfi=Zp RCHITE on ION
a EcMWn l my plans shall W used as pts ie rernrds
Y;LL 1- Licensed Professional
5 OWNER-BUILDER DECLARATION
E 1 hereby affirm Nn I am exempt from the Conuactne-License Law for the
COC following reform.(Section 7 W 1.5,Buvineu and Rufessiuns Code:Any city or county
�'�a'2_9 which requires a permit to Co.,.Wax,improve,dendfi h,re-pair say swed-
prior or its issuance.alar,manias the applicant forsuch permit to file a signed ammment
—s�s< Nat he is licensed pursuanunNepmvisiomnf the Contractor's Usemc Law(Chapter 9 Sq. Ft. Floor Area Val u$tip2OOO
xFm (commencing with Section 7")of Division 3 of roc Huai"••,and Professions Code)or
i $ that W is exempt IWrefmm and the basis for the alleged exemption.Any violation of
Section 7031.5 by any applicant for a permit subjects the applicant m a civil penalty of APN Number Occupancy Type
not more Nan five hundred dollars($500).
❑1.uownerofthepmpwy,rrmyemploymawithwa udtckwiccompcnution, 36217018 . 00
will d"the work,and IW swcturt is nrtim ended muttered forsale(Sec.7014,Business
and Professions Code,The Conuactur's License law does.1 apply to an owner of Required In a ons
propenywhs Wilds or impmwsohereon,and whodoessuchwmk himsedfor through his D� (
own employees,provided Nat such improvements aw nor intended uroffered for sale.If. V\
however.the building or improvement is sold within one year of completion,Ne owner-
Wilder
will haw,the burden of proving that he did trot Wild or improve for purpose of
sale.).
❑1,as owner of IW property,am exclusively contracting with licensed conmcbn to
construes the project(Sec.7064.Business and Professions Code:)Tie C"avenues U
come law does not apply to an owner of property who Wilds or improves thereon,and
who contracts for such pmjeco,with a eonsacmr(s)licensed pursuant in the Contractees
�sensc law.
I am exempt under Sec. .B&P C for this moon
Owner Date
WORKER'S COMPENSATION DECLARATION
Rh1 hereby affmm under penalty of perjury one of the following declarations:
aw and will mif¢
einfew a Cer ,to of Contem tu self-insua for WmIxeesCompcn-
suion,as provided for by Section 3700 of the Labor Code,for the performance of Ow .
work for which this permit is Wood.
0 1 have and will maintain Work u's Compensation Insurance,as required by section
37M of the labor Code,for Ne performance of the work for which Nis permit is issued.
My Worker's Compemadon Insutance carrier and Policy number an,
Cartier: Policy No.: _
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(This section need ort W completed if the permit is foronc hundred dollars(SIBD)
orix .)
1 certify Nat in Ne performance of the work for which this permit is issued,l shall nor
empluyanypenon ncyay��bec9"th„s cot t"tW Workeri Compensation
(awsof Colifomia.Da ��f J11�i��1i L/�C
Appl¢'ant
NO"I'C"APPLICANT:IL of r mg this Certificate of Exemption,you should -
bccom subject AP.
the Workm's oQ nation provisions of the Labor Code,you most
.J Z
forthwith comply withsuds prnAsinns or this permit shall W decmcd revoked.
CONSTRUCTION LENDING AGENCY
[—� IWreby.M.that the.is acomwetinn lending agency lnr Ne performance of
(Y, the work fur which this permit Is issued(Sec.3097,Civ.C.)
I, P
LeadersIName,
a landees Address
J Q I cenity Net 1 have read this application and stow Out the show information is
0 F correct.I agree ct comply with all city and county ordinances or aM showt laws relining ro
pU ithownmentioned prmandhetubyauOronwreprvcnuoivssof Nis city menses upon Oe
fS.l abovcmemiuncd property for inxpccurn purposes 1
F y (We)agree 1. tr
save.indemnify and op bound.the City of Cupertinr against
H liahilitiex,judgmenu,cuts and expenses which may in eny way accrue against said City
U Z inconsequcnccofthegranung ith'i'mroit.
APPLICANT UNDERS A S AND WILL COMPLY WITH ALL NON-POINT Issued by: Dale
SOURCEJIEGUL TI S
q 19 UGI Re-roofs
naturcrfApla, UConsacmr ate
/ HAZARDOUS MATERIALS DISCLOSURE Type of Roof
Will a piicant or future building occupant store or handle hxxardous material
as defined b Cupertino Municipal Code.Chapter 9;12,and the Health and Safety
Cake.Seed 25533(.)?
E]Yes All roofs shall be inspected prior to any roofing material being installed.
Will the applicant or future Wilding occupant u¢equipment or devises which If a roof is installed without first obtaining an inspection,I agree to remove
,o hazardous air coomminams as defined by the Hay Area Air Quality Management all new materials for inspection.
Disuin?
[3y. ANO
I have read roe hamrdous acro Ismquiamcnuundcr Chapwr6.95ofthe Califon
iiia Health&safety Code,S=u 25 5.25533and25534.lundefamnd OwiflW Wilding
Jon not currently haw a tonuffi,th lsyn it is my noprnsibily the occupant of the
requisemczwhieh m j of
uawissuaneeoracen wow urcy Signature of Applicant Date
owner pr arthro-d a nt „e All roof coverings to be Class "B"or better
/I