05100230 CITY OF CUPERTINO
BUILDING DIVISION PERMIT �g,QNTRAQT0R'jNF�QRMATIQN'5
BUILDING ADDRESS: PERMIT NO.05100230
01425 R
7ATRCCHTTECTIENGINEER:
NER'S NAME: PERMIT ISSUE OATS
TINA TRABOOKIS InIll
NE:
SANITARY NO. CONTROL NO.
BUILDING PERMIT INFO
PLUMB MECH
LICENSED CONTRACTOR'S DECLARATIONIOb DOSCrlptl0n
m1 hereby affirm that 1 me IixnsM made,Provinces of Chapin 9(commencing
.ZEwith Section70010of Divinon3afthe Businessand ProfenionsCode.ard my license is
e« in fullfaroeand.ffea P ��a�gS REPLACE WINDOWS & SLID DOORS
'�� License°
ena Lk.g9� CONTRACTOR: A TO Z HOME IMPROVEMENT
CmnlDECL
As shall
ARCHITECTS DECLARATION
1 i 1 understand my plans shall o used to public rncarN
)yU
eaG Licensed Professional
3 OWNER-BUILDER mDECLARATION
t�aC I hem o a(Ern that 11. exempt from the Contractors e:A n c Law for to
O O following moor.(Section R13 L4 Business and tw.dedons Cole:Any city or county
rtme
<3V which rcquin.a penult m crnstrac4 ilter,improve,demolW,or repair anY urueture '
prior to its issuance.also nequins the applicant for such permit in Ek a signed sutemcnt
< Nat ho is licensed punuantm the Provisions of Ne Contractors Liana Law(Chapter9 Sq.Ft. Floor Area Valuati$tpg91
itH (commencing with Section]000)of Division 3 ofthe Business and Professions Code)in
y $
that o u exempt therefrom and the buns for Be.alleged exemption.Any violation of
Section 7031.5 by any applicant for a Permit subjects the applicant o a civil penalty of APN Number Occupancy Type
not mors Nan five hundred doll.($500). 32641052 . 00 p y yp
❑I,u owner ar Ne property,m my employcu with wages ss Jen sole evmpensadan,
and Prfeamlt andthe he ComernoesLt darawchif,act apply aDa6,Bunnm
and Progeny
wh W Cade:The Canuecwrs and
law dam act appy lf rt mvmr of _ Required IDSpeChODS
own
enywhoofIdsvii Bell such imr and who aressuchwork himselfar tluough hf.
however.the es.provided ori provehimprosemenuartmt earrocdmoffcrd f analrsele.If.
however,the athWilding or imPro provinu salt within sae year of mprove for
Ne ower-
builder will base the burden of proving that k did set Wild in Improve far puryoe of
seem.).
1,as owner or de property am exclusively contracting with RestIaeE mmia ms in
construct Ne es not (Sec.n an owner
of and Profasnau Cade:)M Contra.ors fid
come Law dose not apply b m owner of proPertywho Wilds or improv Contra and j
whonse La u for such projects with a contrxtor(s)licensed pursuant w Jse Canvxtors
ElIma Law. -
❑lamexcmptundoSee .BBPCfor this rtsson
Data
pour WORKER'S COMPENSATION DECLARATION
1 hereby affirm under puWty of perjury,ore of the following declarations:
❑Iharcand wJl milnuinaCertifiate of Consentdxlf-insure fm War4YSCmnpen-
atien,nsprovided far by Section 3]00 of Ne labor Cotle,for Ne pertasmars of No
work for which Nu permit is issued.
❑1 have and will maintain Workers Compensation Insurance,u scquired by Section
37W of the labor Cade.for Ne performance or Ne work for which this permit Is issued. '
My Wculmrsgmnpcmouhm Insurance ani.said Policy number are:
Grrier. Policy No.: 'Sf
CERTI CATS OF EKEMPnON FROM WORKERS'
COMPENSATION INSURANCE
(Thuaectim need on,o completed if the permit ufur.hundred dollars($100)
or less.)
I CWafY Not in the performance of the wails for which this permit is issued,l shall not
cmPloymy person in my ma➢ner bice csub' to de Workeu'Co—MIZa'or
Laws of California.Dae — —� -
Applicants
NOTICE TO APPLICANT:If,after making that Certificate of Exemption,you should
Weems subject In Ne Worker's Compensation provisions of the labor Code,you mut
., z forthwith comply with such Provisions in this Permit shall o deemed revoked.
zCONSTRUCTION LENDING AGENCY
E--� Ibarely afnim Nat Nem u a consuvction to lending agency for perfonnana of
!Yi>
Use work for which this Permit is issued(Sec.3097,Civ.C.)
4 p Lenders Name
7 z Lenders Address
U Q 1 easily Nn I have read this aPplicalim.and tau Nat Ne shave information is
L. F WMCL I agree u comply with ill city and county onda nes and suns laws relating u
0 V building construction,and hereby auNads repreammardss or Nis city m enter upon the
U move-m onimin d Property for inspecdam purposes
H C (We)agn:e to arc,led cmniry and keep harmless the City of Cupertino agaiw
H Iiabilitins.judgmcini. auand expenses which may in SAYwaYminu
aue agaaid City
t)z in Wesequtence of the granting of this K.iL
^ APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT Issued by:• Date �(�--3r -z'
�—
SOU� REGULATIONS.
Re-roofs
Signature of AppliaDOU Dau
HAZA
HAZARDOUS MATERIALSDISCLOSURE Type of Roof
Willy t applicant or future Wildingk,Chapter 1,
handle Health anmatenil
u defined by Nc Cupertino Municipal Code.Chapter 9.11,and Ne Health and Safety
S.W..y2ss3z(a)? All roofs shall be inspected prior to any roofing material being installed.
❑Ym ❑ u
Will the applicant or tit/ort builJing empam tax cyuipmcnt or Jcvices which If a roof is installed without first obtaining an inspection,I agree to remove
emit haraNnus air canumieanu as defined by the Bay Arta Air Quality Management all new materials for inspection.
District?
❑Yex 10No
Ihaus mad the hva lies materials mquirenenu under Chapter6.95 olthe Califor- --
meHalNhSafetyCode,Sections 25M.25533 amd255N.I understand deatifNe Wilding
des rat currcn0y have•unanL that it b my nolusihility m annify the occupant or Be ✓�rG /_�/��J --
require fits whichmow he at Prior to Mo.of a certificate oraapary. Signature Of Applicant Date
Owner or auNarirsd aicm DateAll roof coverings to be Class"B"or better
' '