06030080 (2) CITY OF CUPERTINO
BUILDING DIVISION PERMIT PCONT'RAG'I�nR IN 'o e In`�r�o '
!= 4�.�- z= k'-�.
BUILDING ADDRESS: PERMIT NO.0 6 0 3 0 0 8 0
11260 CATALINA C
OWNER'S NAME: PERMIT ISSUE DATE
MR. AND MRS . FA 006
E: SANITARY NO. CONTROL NO.
ARCHITECTIENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
ioo LICENSED CONTRACTOR'S DECLARATION
t Job Description
�+ 1 Wreby affirm that 1 sm Ikmnecd under pmvWans of Chapter 9(commencing
with Section 7000)of Division 3 of the Busineu and Professions Code,and my license is
+ in full to=and affect. ADD (M) BEDROOM, BATH, ALTER BR #4 & MODIFY
? License Class Lle.k
Date contractor REMODEL 140 '
ARCHITECTS DECLARATION
1 understand my plat shall be used is public rommi,
yy6
G�m Licensed Pnttcsaionel
or 3 OWNER-BUILDER DECLARATION
1 hereby atnm Not O 1eattempts a the Cenio License Law for tier d
following actors.(Section NO1.L5,Business ad Professionsn,Code:Any airy or county
S9 Which requires a lummlt to consensus,alms,imixove.demolish,or repair my arumum
-iy prier to its Wuancc.ala mqulm,lhcapplieal thrash permit to file.signedsu enaL Val aZ10�8.rJS
E dun he a licensed Pursuant W the provisions order Centime,Limns:Low(Chmer,9 Sq.Ft.Floor Area
e�9 (commencing with Section 70D01 of Division Sof die sa Budncexi Rafesdhns Code)ar
egg that he is exempt therefrom and the bads for the alleged assumption,MY Wealden of
Section 7031.5 by cry appllamn fon a permit subjects the suppliant W a civil Penalty of rOccupancy Type
at mart the Rw hundred dellen(1500). 3.7 O GU�7 . 0 0
❑i,v awrerr o(de WOPernY,a my wPlayev with wages v de's seWmmpenutia,
will do the work adds suucta,is.1 intended a offered forsam(Sec.]ON.Bud. Required Inspections
ad Profeadnv Cade sa
The Comt m's License law elect at apply to a Owner of q P
Property who build,Or impresses thereon,ad who does such wort himself or through his
awn employers,provided thatch imp.ts art at intended oro@sad forsaie.E.
however,the building Ot Improvement Is aid within aro Year of mmPlenOm.the owner-
builder will have de burden of pmvinC Oil W did at build re insProw fon Purpose of
tile).
I$1,a.Owner of We propenY•am nxclusivelY contracting with licensed amuacmn W
consumer the project(Sec.70M.Business ad Profrsdam Code:)The Cavutoh Li-
cense Law does not apply to an owner of property who Wilde Or Improvns Warton,ad,
who contracts for such projects with a conuactar(U licensed partial to the Committees
License Law.
❑I an tempt under Sm .B d P C for this meson
N
D.te 6
RI vTPENSA ON DECLARATION
I hareby Nim under penalty of perjury oto of the fallowing declaviose
❑Thaw And will maim i.a CaNReouot Conran in elf-inert forWorkees Crmpea
.due,v provided(a,by Section 3700 of the tabor Code,far W part.. m of the
work for which this permit is blued,
❑1 haw ad will maintain Wmkals Compensation Insurance,as acquired by Semis
3700 of the Labor Cade.fon the performance of the work fawhich this Permit is road.
My Workefs ChmpemtWa baunnce tamer,and Policy number Me:
Carver. Policy No.:
CERTIFICATE OF EXEMPTION FROM WORKERS
COMPENSATION INSURANCE ,
(This account need atWcompleted Bade permit Is forma ha ftB ($100)
or kis)
1 comfy that in the paromace of Ne work for whirls this permlt is Wad.l shall in
employ myperson in my meats I tt m bmto Me Warimn'Compensation
L."of Califomis D.W
Applicant
NOTICE TO APPLICANT:If,4&r making this Cendfictim of Exemption,you Mould
become abject he the WhrkeYs Compensation provisions of the Lebo Code,you most
'JO forthwith comply with each provisions Or this permit Mail W dermed melod.
„Z„ti CONSTRUCTION LENDING AGENCY
f" I hereby afflm that mem its construction lending agency for the performance of
tri,> me work for which this Permit Is Wised(Sec.3097.CW,C.)
QLenders Nan. '
z
Leading;Addres
U Q I certify that I have mad this application and suer that the show informed..6
IT. F
correct.1 agree to comply with all city and county a dim errs and sus Isws relating to
Qbuilding construction,and hereby athhdu represenaiws of this city la cnterupnn the
�U above-mentioned property for inspection purposes
(WO)agree to saws indemnify ad keep harmless the City of Cupenino.gainst
rF.rcA lisbilidesjudgmem,,tofu elopeases which may In my my acese against said City
Uz incarvegtrstec O(thegrmdogef upermkt
^ APPLICANT'UNDERSTAN AND WILL COMPLY WITH ALL NON-POINT Issued by: Date
SOURCER ONS. '
Re-roofs
Si ofA HaAZAROUS MATERIALS DISCLOSURE a Type of Roof
Will de appliont or fount,Wilding e(muPat arm or media haaaNrns material
v deRned by the Cupertino Municipal Code.Chapter 9.12,ad the Health ad Safety
tie.Section 25!32()7 rho All roofs shall be inspected prior to any roofing material being installed.
❑Yrs
Will the applicant or future building occupant use equipment or dcvim..which If a roof is installed without first obtaining an inspection,I agree to remove
emir hoard...alr canumin our a defiad by dm Bay Area Air Quality Maagcmcnl all new materials for inspection.
District?
❑Yes k7 u
I have read the hvardtas models requirenernu underChapa 6.95 or the Califor.
nia Hcal"Safety Cuda.Sections 25505,25533 ad 25534.1 understood that irte building
Jona not currently how a morns, t It is my responsibility to notify the occasion of the
requiremen must WpdorwiuuaceofacardOtmof f2 Signature of Applicant Date
6 All roof coverings to be Class"B"or better
ncrw oriud agent Dam'