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04040179 (4)+M2 2 36c LL 5q0. p< _Ze H_r�F_rS� Fit L 00 Z r fn W Q �z UO_ OF U CITY OF CUPEIITINO ^.w^�K" vt? a "+� BUILDING DIVISION - p];R T rG01\ I� TQR INl'®�MATION , ' BUILDING ADDRESS: EARS HOME IMPROVEMENT PERMT14040179 OWNER'S NAME: PERMITLSSUEDATE 04/28/ 2004 HONE: SANITARY NO. CONTROL NO, (925)245-2000 ARCHITECUENGINEER: BUILDING PERMIT INFO BO ELQECf PLUMB MECH m that ILICENSED CONTRACTORS DECLARATION I affirm that l am limned under provisions of Chapwr 9 Job DCSCriPhOJfaO LFR with um 7 n Divixion3 of NC Business and Pmfessinns Code, and myliccnu is i my license • k1 Y31ss"'A O llfor and in,m.C1amermc` dafec IDING (792 SQ.FT./RIGHTSIDE ONLY )� LiccnuClnsa Llc.r Dart Contractor MAY 1'j 2004 ARCHITECTS DECLARATION CL 1 understand my plans shell Ire used u public rtenrm i BUILDING ' Licensed Professional I OWNER -BUILDER DECLARATION eV'�t�A� . 1 hereby affirm that I am exempt from the Contractor's License Law for the fallowing rtaun. (Section 71A L5, Business and Professions Code: Any city or county which requires a permit to commul, alter, improve, demolish, or repair any structure r 5 Prior to its issr.ace.aim squires the applicant rorsuch Permit to file a signed statement 1 that la, is licensed pumant to the Provisions Of the Contractor's License, Law (Chapter 9 Sq. Ft. Floor Area Valuation (commencing with Section 7000) of Division 7 of the Bminessand professions Code) or .. Net t he is exempt themfrom and Ne basis for me alleged exemption. Any violation of Section LSaapplicant for carmit aubjecu the applicouo acivil pcnehy of 326AENN3m16C0 OCCI -Type not momthan five hundred d...($5 aWc ❑ 1, as owner of she import , or my employem with wages as their auto compensation, will do the work, end the structure is not intended oroffemd forsale (Sec. 7041. Business and Protrusions Code: The Contactors License raw does at apply u in owner of .- Required Inspections Pmpeny who builds or impmves mertron,and whodoes such workhimulf or through his own employees, provided that such improvements arc not intended oroRered for Ile. IL however, the building or improvement Is sold within one year of cemPletioe. me owner. builder will have the burden of proving mat he did not build or improve for purpose of sale.). ❑ 1. as owner of me property, am exclusively contracting with licensed cemncmra to compact me projcet (Sec. 7004. Business and profusions Code:) The Contractors Li. mrue law deal not apply to an owner of property who builds or mint to mon, and, who contacts for Such projects with o contractor(s) lieemed Pursuant to tw Communes Liceee Law. ❑ lamnemmundo(Sec ,BdaPCfmthisrecon Owner Date WORKER'S COMPENSATION DECLARATION Ihereby M. under Penalty of perjury one of the following declarations: 1 haw and will maintain a Certificate of Consent o ulbinsuu for Work es ComKn. cation, an provided for by Section 7700 of the labor Code, for the performance of me work for which this permit is issued. ❑ 1 have and will maintain Workers Compensation Insurance, as required by Section 7700 of he labor Code. for the performance of the work for which this Permit is issued. My Workers Compensation Insurance canner and Policy number am: Cartier: Policy No.: _ CERTIFICATE OF EXEMPTION FROM WORKERS' COMPENSATION INSURANCE mos uellnn need not w completed If the permit Is for one hundred dollars n1BOB or lcsx) I certify that in the performance of me work for which his Permit is issood, 1 shall nut employ any Peron in my manter u as u become subject o the Workeri Compensation _ Laws of California. Data Applicant NOTICE TO APPLICANT: If, after making his Certo icate of Exemption, you should _ bmome object m the Worker's Compamsan on provisions M the labor Code. you ..in - ' forthwith comply with such provisions at this Permit hall w deemed ievoked. CONSTRUCTION LENDING AGENCY I herby Affirm that mem its compaction lending agency or me Performance of the work fur which this pewit 11 issued (Sec. 3M. Co. C.) Lender's Name Lender's Adds I clmfy that 1 have read his application and sure Bat the above information pa Correa 1 agree to comply with all city sed county oNinanms and sue laws raising in Wilding construction, and hereby autharirn op eunativu of this city to enter upon me awvcmejudg d property for Inspection (We) agree to ave, indemnify and keep harmless the City of Cupertino against which may expenses which may in any way accme against said City inconsequenc Of meceaseand of me granting of this permit. A APPLICANT APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON -POINT Issued by: Date SOURCE REGULATIONS. ' Re -roofs Signature of ApplicaDate HAZARDOUS MATERIALS DISCLOSURE Type of Roof Will the eplm forum wilding occupant store handle l a defSed by the Columbia Municipal Code. Chapter 9.12. ad the Hesith and Safety Code.23532(.)? ❑rm ON. All roofs shall be inspected prior to any roofing material being installed. Will the applicant Or future wilding occupant are equipment ordcvima which If a roof is installed without first obtaining an inspection, I agree to remove mitistrhaiudnus air cameramaict?n.u JcOncJ by he Bay Arta Air Quality Management all new materials for Inspection. ❑Yes ❑Ne 1 haw mad me wurdous materials requirement.; under Chapter 6.95 of me Cali for nice Health@ Safety Code, Smtiem 25515, 25577 and 25574.1 un@aund this irhe wilding Joexi not currently haws mmol. that it a my responsibility W andfy me axupat of me "toornenks which mom wtact prior u iauanm oft Certificate of Omupamy. Signature Of Applicant Date All roof coverings to be Class "B" or better Ownelm.mh rimelagent DateI J ai C CITY OF CUPERTINO(-�ono- V - - BUILDING DIVISION PERMIT CONTRACTOR IINFORMA.TION-f BUILDING ADDRESS: - - EARS HOME IMPROVEMENT PERA°1314040179 OWNER'S NAME: PERMIT ISSUE DATE AT.RRRCHT qCT40Y )R3 R_ AIRWAY RIND 2004 PHONE: SANITARY NO. CONTROL N0, (925)245-2000 ARCHITEC (ENGINEER: - BUILDING PERMIT INFO BGEG ELECT MECH LICENSED CONTRACTOR'S DECLARATION' I hereby ChapterCode 9 Job Description P affirm that am ftheBO under vision Of(commencing With section 7000) Diviaion3of the Business and Professions Code, and my license is dark Licenforte Rdeffe IDING (792 SQ.FT./RIGHTSIDE ONLY) ' Li DatecG Dale COnlr it AR ,:HEl s DEC 1 , 1 unde'stand eny plans shall be used es pis O ocmds( ~i. Licensed Professional OWNER -BUILDER DECLARATION I hereby affirm that I am exempt from me Contractors License Law for the following reason. (Section 7131.5, Business and Professions Code: Any city or county which requires a permit to construct, site, improve, demolish, or repair any structure 5 prior to its issuance, also requ rcs th. applicant for such permit m rile a signed statement that he la0censedpursuant ,otheprevi.innoftheContractor'LienseLaw(Chapter9 Sq. Ft. Floor Area Valuation (commencing with Section 7") of Division 3 or the Business and Professions Cade) or Nu he is; exempt there0ons and the basis for the alleged exemption. Any viola0on of Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of 326fl1 1919,1@0 Occupancy Type not mere lean five hundred dollars (M). P y ❑ L as owner ofthe property, or my employees with wages u their sole compensation, will do the work, and Be structure is not intended or offered for sale (So.. 7W. Business and Professions Code: The Contractors License Law dors not apply to in Owner of Required Inspections Property who builds or improves tbercon, and who does such work himself or through his own employees. Provided that such improvements arc not intended oroffa nd for We. IL however, me building or improvement is sold within one year orcomPletion. the owner. builder will have the burden of proving that he did not build or improve for purpose of alk.). 0 1. as owner of the property. am exclusively contracting with licensed contractors to construct me project (Sec. 7094, Business and Professions Code:) The Contractors Li cense Law does not apply to an owner or property who builds or improves thereon, and who contracts for such projects with a contractor(s) licensed pursuant m me Contractor's License Law. ❑ I am exempt under Site ,B&PC for this .,on Owner Date WORKER'S COMPENSATION DECLARATION I hereby affirm under Penalty of perjury one of me following declarations: ] l have and will maintain a Certificate of Consentto at l f-insum for Worker's Compere Whin.u provided for by Section 37M of me labor Cade, for me performance of the work for which this Permit is issued. _ ❑ 1 have and will maintain Worker's Compensation histamnm, ss required by Section J7�C�fformaoccn.e of the work for which this permit la iuucd. ^� strier and Polirvym E�r}(�s,.g,lPolio No,. �2^^�a'MPIONFgfJ 0 KE S COMPENSATION INSU AN E (This section need not he completed if the Permit is for one hundred dollars 1$101) or loss.) 1 certify that in the Performance of the work for which this permit is issued. l shall not employ any Porton in any manner an u to he lam, subject to the Workeri Compenemion I. of California. Dal. Applicant NOTICE TO APPLICANT: IL aR., making this Certificate of Exemption, you should Become subject so the Worker's Compensation provisions of the labor Code, you must forthwith comply with such provision or this Permit shall be deemed revoked. CONSTRUCTION LENDING AGENCY 1 hereby onium that there is a construction lending agency I'm me performance or tht, work for which Illi. permit is issued (Sec. 3097, Civ. C.) Lender's Name Lender's ddress certify that I mal 1 have read this application and dote that the above information it CORCc6 1 ag2C ct comply all city and county Ordinances and.ale law. relating to g buildingconstruction.and hereby here Of rposeumativcs of this city to enter upon the neo property for inspection pulposis. inspection (We) to indemnify keep harmless agree sive, and the City of Cupertino egainsl Iiablli ics,judgmrn6, costs and expenses which may in anyway acerae ago nal sold City in consequence on equen ofthegrantingof this permit. A APPLICANT APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON -POINT Issued by: Date S C GULAT S. V' Re -roofs Type of Roof AAD 4;V_ al Applicant/Conlra or Dara HAZARDOUS MATERIALS DISCLOSUR Will the applicant or future building occupms.mfe or handle haamous material as defined by the Cupertino Municipal Code, Chapter 9.12, and Be Health and Safety - cmle.Section z553z(a>? ❑Yd '{�Nu All roofs shall be inspected prior to any roofing material being installed. Will the applicant Of future building occupant use equipment or devices which If a roof is installed without first obtaining an inspection, I agree to remove it har rdous air contaminants u derined by the Bay Area Air Quality Management all new materials for inspection. is¢lct? 1 CYca �1Nu I have mad the haxormais\mmerialsuyuimments under Chapter6.95 of the Courts. nialicalth&Safety Code, S¢don 25505, 25533 and 25534.1 undersand that if me building dors ncurrently have a tenant. mat 11 is my responihility m notily the oecupanl of me imotmons which mPdo to issuamce on cc"$cam of Occupancy. Signature of Applicant - Date dDate raumod.ed em All roof coverings to be Class "B" or better