06030125 CITY OE CUPERTINO �`' `'''
BUILDING DIVISION PERMIT vCONTRACTOR INFORMA"�IQN:'
BUILDING ADDRESS: EVERGREEN DC CO (LHC) PE""'06030125
10486 WESTACRES DR
WZPERER'
1173-D S DE ANZ
PHONE: SANITARY NO, CONTROL NO.
(408) 884-2429
ARCHnECTIENGINEER: BUILDING PERMTTINFO
BLDG ELECT PLUMB MECH
iOp LICENSED CONTRACTOR'S DECLARATION ]Ob Description
M1 hcmby affirm tat 1 en licensed under provisions of Clan-9(commencing
it Seem.T000)of Division 3 of de,Business m mail PratuniuCode, my license is
+�„ infull fame and effect REVISE PLANS DUE TO ,ORIGINAL LOT LENGTH ERROR.
iq? LicenseClass ueP
Date
ORIG 1061 SHE BE 1021 -4 3/1611
Dam ARCHITECT'S DECLARATION ORIG PERMIT 05100038-NO NEW PERMIT/IN HOUSE ONL
f m< 1 undersand my Plans shall he used as public retort
5yU
'o Licensed Profl
essiona
3 OWNER-BUILDER DECLARATION
1 hcoby affirm tot 1 am exempt!ruin is Convaelofa License Law for the
o O following mason.(Section 7031.5,Business and Professions Cale:Any city or county
1@9 which mquires a permit to cnnarwt,sher,mil on,demolish.or repair any structure
_i` prior m its issuance.also require to applicant foreach permit to Ek a signed sugmcm
tat he is licensed pursuant to tW provisions of to Conmactur's Liccmc Law(Chapmr 9 Sq.Ft. Floor Area Valuation
(commencing with Section?000)of Division 3 of dac Business and Professions Code)or $0
i? 9 dsu he is exempt therefrom and to basis for the alleged exemption.Any violation of
Section 1031.5 by any applicant for a permit subjects de applicant On a civil penalty,of APN Number Occupancy Type
trot mom tan fin hundred dollars(150)).
❑l.nO wrof Biepmpwy,mmyemploycowitw Mud &wkcompc=don,
will do One work and dtestmctm isnminumdW moffemd forsate(Sec.7014,Bun.
and Professions Code:The Cmuscwra Liceme Law don Out apply t an owner of Required Inspections -
property who builds orimprovn tenon,and who dmsswhwork himself or through his
own employ.,provided tat such impronmwo oe not intended whitened(orale If.
howevm,the building orknpsamne t is sold witin ons year of canplcuou.to owner-
builder ,will hart de,Wrdw of pmHng tat he did not Wild w improve for pmpoic of
ale.).
❑1.a Owner of to property,am uelusively contracting wit licensed comactm to
whereas,to Mimi(Sec.1044.Bestow and Professions Code)The Cwuaeors U
echee law don not apply in an owner of property who Wilds or imposes daemon,and. v
who contracts for such projects who a eommetor(s)licensed pursuant an to Commusm's
License law.
I.esBh PCfm to
Nib,! �7 _ Dam I- 7
WORKCOMPENSATION DECLARATION
I bemby affum under penalty of perjury ore of the following declaratiarsc
❑1 haw and will maintain a Certificate of Chnscm in sel6insum fm WariecesCompen-
melon.as provided your by Scenes 3700 of the tabor Cak.for the pidarmara¢of the
work for which this Permit is issued
❑1 have and will maintain Worker's Compensation Insurance,as required by Section
3700 of to Labor Code,for dac pdo...of the work for which his permit is owned '
My Workeh Compensation Insurance tauter W Policy number art:
Caries Policy No.:
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(This accost wed not W completed if to permit is futons hundred dollars($100) r
or Ins.)
1«nlfy but in de performance of she work per which his permit is ismed.I shall.1
employ any Olson aaAhecoOn subjmt to tc Workcswati
s'Compeon
Laws of Califamit
Applicant
NOTICE TO APPLICANT:If.miterf6scing tis Certificate of Exemption,you should
become subject to the WmkcYs Compensation provisions of the lebw Cam.you most
.,O formwice comply who such provisions or tis permit shall be deemed revoked.
z� CONSTRUCTION LENDING AGENCY
[•w I hereby affirm tat tools.conslructe,lcMing agency nor the pmpormanma
cd > to work for which this permit is hated(Scc.30971,Co.C.)
1 A Lender's Name
=z Lender's Address
U0 I certify tat I ban mad this applicwion sodium tat the aWn informauun is
Li. P corms.I agree to comply wit all city and county Omination and sum laws misting in
0 building construction.and hereby authorise mpresenuuns of tis city to enter upon the
r W ahovomend.mil property for irupeeuon purposes.
4L lac)agree to sen,indemnify and keep harmless f City Of Cupertino against
nFi fA liabiliuu,judgmenu.casu end expenxn which mey in any way acerae against aid City
Uz toconscgwrme.rfli�cgraJ�inigoftispermit.
^•' APPLICANT-UNDERSTANDS AND WILL COMPLY WITHALlll.,,NON-POINT Issued by: Date _/'f -?/�
R •BEG LATIONS, � ,
SO D
/ Re-roofs
Si naum0(Applie'aRam
HAZARDOUS MATERIALS DISCLOSURE Ty
pe of Roof
Will e applicanorfuture
Wilding occupant stere or handle hosardoor and Sgrial
az OcBnsd by em Cupertino Municipal Code.Chapter 9.I2,and the Hent and Sffiry
. 0y.ecdon zss32(a)? All roofs shall be inspected prior to any roofing material being installed.
❑Yin ((�No
If a roof is installed without first obtaining an inspection,I
Will to applicant or fumes building weapon,tax equipment Or devices which g agree to remove P
emit be,amon air conuminanne as defined by tc Bay Area Air Quality Msnagcmcnt all new materials for inspection.
Cleric,?
❑Yca <No
1 have mal to Wood. underChapterfi.93 o(tW Califon
nix Health SafoycodiuSenl�te 23303.25533 and 25534.1 aakerrand to irte Wilding
doesnot cu IY hoc a gmnA that it u my responsibility at notify ft upon,of dm
rtyuir mf yswhich muss_ be MCI Poor missuawe nracemrgaghrycy, Signature of Applicant Date
Ownm or amhu rad operon 3
4-7, Signature
II All roof coverings to be Class "B"or better