05020084 CITY OF CUPERTINO ' -
BUILDING DIVISION PERMIT 4CO1V"�kAGTOI21NI tSRMATIUN:-
BUILDING ADDRESS: NICE & RIGHT CONSTRUCTION &""05020084
OW-,1811 qAN 77PNANT)r) A17
NER'S NAME: PERMIT ISSUE DATE
TRA
ONE: SANITARY NO. CONTROL NO.
CHITECr/BNGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
0 0 0
o O LICENSED CONTRACTOR'S DECLARATION
1 hereby".me,1 am licensed ander pmv6lans of Chapwr 9(mmmcneing Job Description
m nim ec6.n7M)ofDirndon5oftie Badmasand Professi Code,andmylwenseh
^` in full fortt and slice,. Z/ S DEMO
5 g z Liaose Chas lAe.a
�F Daw Contractor VALUATION CHANGED--PER OWNER (12/15/05)
CHnEC'S DECLAR N
I understood my plans MVI he used As public records
3
ad�
Licensed Professional
OWNER-BUILDER nexempt
DECLARATION
f I krehy.Sect too 1 I.S.exempt from the deenm.Cod LXann law for the
O O following reason.Section 71Yd 1. Business and Professions Code:Any oily or county
$ which requires a permit in consumer.star,improve.demolish,or repair any structure
h > prior a its issuance,Arm requires tie applicator for such permit w Elc a Ngnodsulement
iso that k islicensed pursuant w da provisions M the Canusewr's License law(Chapw 9 Sq. Ft. Floor Area - Valuatd011300
$ (commencing with Section 70M)of Division 5 of the Business and Profasiatu Cook)or 4'�
that he 6 exempt thenfmm and the bash fm We alleged exemption.Any violation of
Section 7031.5 by wry applicant fee a permit subjects tim applicant w a civil penalty of APN Number Occupancy Type
not man than five bummed delWa($500).
01.As owneroftie property.or my employees with toga As da:ksom compenradon, 35715082 . 00
will dothewotk,andtheauuaun6notinandedmafiemd mrsele(Sa.7044,Busimas Required Inspection
and Profeselons Code:Tie Canumwnsm b ner
rs License Law dan,apply an owor q p
property who builds or im prow thereon,and who docs suc h work himnlf or INough his
awn employees.provided thmsuch improvements an mtinanded moRased fm sale.If,
however.the building or improvement 6 sold within one Year of completion,the owner.
Wilder ME haw the burden of proving that he did not Wild or Improve for purpose of ��• - l4,
❑1.as owner of the property ton exclusively contracting with licensed canuacan to
construct Ne pmject(Sec.70".Business and Professions Cade:)The Commemar's Li. c+
came law does naupply in an owner of property who Wilda or improves thetom,and,
who contracts for such projects with a eontrecter(s)licensed pursuant In tin Contractors p
LkenessLaw.
m ✓
❑Isaempt undo see. ,Bd:PCfm Wareawn
Owner Dan
WORKER'S COMPENSATION DECLARATION
I kreby al IR
under penalty of perjury one of the following declarations:
hawandwill maintain•Ce lfieamof ConsentioulRlnsumfm Workers Comp n-
n,As providW for by Section 5700 of the labor,Code,fm do peAormenem of the
for which this permit is issued.
❑I Mw and will maintain Workers Compensation Insurance,As required by Section
5700 of the labor Code,for the performance of do work for which this permit is issued.
My Worters Cn pe um on In u a artier end Policy number an:
Card. Policy OM 'D DZO
CERTIFICA COMPENSATIONTION
WOR ERS'
COMPENSATION INSURANCE
(This sectim mad our kcanplend if de permit Is forma hundred dolWa(5100)
or less)
1 cend'y the,in the pas foram of the work for which this permit is issucd.I shall not
employ any pagan in any manner an As w beams subject in the Workai Compertsadon
Laws of Calirurm.Dan
Applicant
NOTICE TO APPLICANT:IL afar making this Certificate of Exemption.you should
Income subject to the Worker's Compass,lon provisions of the La Wr Code,you mat
.J O forthwith comply with such prwm isinor this permit shall k dcemed rewked.
Z r~y. CONSTRUCTION LENDING AGENCY
�.+ I kreby errum that dart is a masuucum lending agency for the performance of
Cli 7 the work for which this permit is Wood(sec.5037.Civ,C.)
QLender's Name
M.
D Z lenders Address /
D 1 ceNfY the 1 have tad this application and saes Nn the above information 6 S
U.
coma I qme to comply with all city and county ordinances and awe laws mlating to
O Wilding construction,and kreby mintaine representatives of this city or color upon the
W M w.racruoned property for Intention purposes.
(We)agree to raw,indemnify and kap harmbss the City of Cupertino agalred
zy liabilities,judgments,costs and exile"-•which may in any way aceta against sold City
()�+ s rmit.
/ ✓ A"'l�
APPLICANT UNDEIn consequence or th,RSTANDS Aof IND WILL COMPLY WITH ALL NON•POINT Issued by: Date J
SOURCE REGULATIONS.
=a Z I L/��SS Re-roofs
Signal a A Iesm/Comrxewr Dan
�° HAZARDOUS MATERI DISCLOSURE Type of Roof
Will the applicant Or future building oaupenl am or handle hvardous maariY
As defined by tho Cupertino Municipal Code.Chapter 9.12.and the Health and Safety
cmc.secuanus5x(.)7 All roofs shall be inspected prior to any roofing material being installed.
❑Ya t6Ma
+ Will tk applicant or future Wilding occupant use equipment m dedaa which
If a roof is installed without first obtaining an inspection,I agree to remove
It hazardous air conumiana a defined by tie Bay Area Air Quality Management all new materials for inspection.
i I rich
❑Yes v(�lu
thew mad the hmsrdousma miahmquinements under Chaperb.95 ofthe Calirm.
lilt Haw&safmYCodc,Sectims 25505.25557 and LSs34.l undcrsaM thulftia Wading
does mol cume.11 how•anent,that It is my responsibility w nntil'y,k aauP.l of the
myvirtmen w umkmet�Four�Issuaneeo�faccnlfieawafOcapancy. Signature Applicant Date
g PF All roof coverings to be Class"B"or better
Owner , mcda ant Dam