07100001 CITY OF CUPERTINO ���� :
BUILDING DIVISION PERNIIT <:
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PERMIT NO.
BUILDING ADDRESS: .
22293 N DE ANZA CL WAUGH THOMAS M AND 07100001
� E M PERMIT LSSUE DATE
R'S NAME: •
WAUGH THOMAS M AND KATHERINE 2 2 2 9 3 N DE ANZA I SANITARY NO. CONTROI. NO.
PHONia
BU►LDING PERMif INFO
ARCHITECT/ENGINEER: BLDC ELECT PLUMB MECH
� � � �
� Q a LiCENSED CONTRACfOR'S DECL4RAT[ON JOU DeSCi11Jt10I1
: ti� I hcccby af[itm �hat I am licenscd undcr provisions oC Chaptcr 9(comrocncing
; Z� with Scction 700Q) of Division 3 oClhc Busincss and Profcssions Codc, and my licensc is 115 .S Q F`I ADD I T I ON � 4 � � S Q REMODEL , NEW 2 � � AMP
>> y in full forcc an d e( fec� ��c. u PANEL � 9 SKYLIGHTS � GAS LINE � S M O K E D E T E C T O R S
j� � Licensc Class
: F � Da � ARCHITECI'S DECLARATION THROUGHC �UT . 4 O O� X 1 O O. 7 r J
j� �
1 undcrstand my plans shall bc uscd as public rernrds
)yU
° u. y Licenscd Pm(csaional
� � e OWNER-BUILDER DECLARATION
� t� 1 hercby at7rm ihat 1 am excmpt Gum thc Con�ractor's Liccnu Law for the
p o following rcuon. (Scction 7(131.5, Busincss and Profcssioos Caic: Any city or rnunty
�°„ �i which requires a permit to conswct, alur, improve, dcmolish, �r repair any struccurc
°" y prior ui ils issuancc, alsu ccquires the applicant Cor such permit w filc a signed stalcment S Ft. Floor Area Valuation
-?< that he is IicenscJ pursuanl �o thc pmvisions of thc Conuacwr's Liccnse Law (Qupter 9 q• $ 6 4 9 5 2
,�-� F� (commencing wiih Section 7000) of Division 3 of Ihe Business and Professions Code) or
y�„ tha/ he is exempt the�cfrom and Uie basis Cor the allegcd ezempUon. Any violauon o( QCCU 1I1C T e
Section 7031.5 by airy applicant for a permit subjecu the applicant w a civi] penalty of �. pg�1 Number P Y YP
not more tNan five hundred dollars (5500). 3 5 6 � 2 0 2_�
❑ I. as owner o( ttie propcny. ar my employca witt� wages u Weir sale rnmpensation,
will do the work. and the stcuctucc is not inknded or offered forsale (Sec. 7044. Buaness Required Inspections
and P�oFessions Code: The Conuacwr's License Law docs �ae apply w an owner of
proparty who builds ot improves thercon, and who does such work himxlCar Nrough his
own employccs. provided that such improvemenls are not in�ended or ottered [or sale. I[.
however. the building or improvement is sold within one year of compledon, ihe oweer-
builder will have Uu burde� nf Pro��ng �hat he did not build or improvc tor purpose of
sa1cJ.
�owner of �he propcny. am ezclusively convacting with licensed rnnvacmrs w
conswct ehe pcojea (Sec. 7044. Busincss and Protcssions CadeJ The Cuuuvactors Li-
cense Law docs not apply to an owner af propeny who builds ar improves WeROn. and .
who wnuscts for such projects with a convactor(s) Iicensed pursuant w �he Convxtor's
L �� � , B& P C for is
^ I am uemp der See �
_� Date
WORKER'S COMP ON DECLARATION
1 dereby affirm under penalry of perjury onc o( the tallowing declaratia�s:
❑[ hsve and will maintain a Certificate of Conscnt lo sclf-insure for Workers Compen-
sation, as provided for by Sectian 3700 of the Labor Code, for the performance ot �he
work (or which Wis permit is issued.
❑ I havc and will maintain Workcr's Compensadon Insunnce, as �cquired by Scction ,
3700 of thc labor Codc. Cor the pcdormancc of �he work for which �his permit is issued.
My Workefs Compensation Insucance camer and Policy number are:
Cartier. Poliey No.:
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSAT[ON INSURANCE
(Chis scctian necd not bc completcd if the pcimit is for onc hundred doltazs (5100) ,
o� Icss.)
I cenify that in thc per[onnancc of ihc work for which this permi� is issued. l shall �rot
employ any person in any manncr so� to 4t�o� mbject io ihe Workcrs' Compeiwtion
Laws of Califom� Datc � � �� ��
Applican� f ` "
NOTICE TO P LICAM: If, aftcr making �his�cniCicaic of Excmpuon, you shoubl
become subjcct to the Worlccr's CompcnsaUon provisions of ttic Labor Codc, you muu
, z foMwitA comply with such provisions or this {+crmi� shall bc dccmcd Rwokcd.
Z � CONSfRUCT10N LENDING AGENCY
E.. i-�. 1 hcre6y a[Tirm ihat thcre is a constnxtion Icnding agcncy Cor thc perfortnar�oe uf
,rY., � thc wock Cur which �his permit is iuucd (Scc:. 3097, Civ. CJ •
W A Lendcr's Namc
a+ L.cnders Address
U 0 ( certitY that 1 have rcad this applicadon and siaic that Urc above infomwtion is
w F cortcc� I agrce �o comply with all ciiy and county onlinances and sute laws relating to
� U building conswction, and heteby authori�e representa�ives of �his city eo enter u�n �c
abovc-mcntiuncd property tor i�spccuon purposes.
�" a (We) agree to save, indcmni(y and kecp hartnless the Ciry o[ Cupertino against
�,E"�„� � liabilities, judgmcn�s, costs and expenscs which may in any way accruc against said �ty
U z in consequencc oC the granting ot ihis permit. DST,C ,�-- ��—°'r'T
� APPLICANT UNDERSfANDS AND WILL COMPLY WITH ALL NON- INi Issued by
SOU REGULATIO . ��
0 7 Re-roofs
Sig uure of ApplicanUConuac a � T of R oof
HAZARDOUS MATERIALS DISCLOSURE YP
wll ihc applicant or futurc building occupant storc or handlc haiardaus material
'cfincd by thc Cupenino Municipal Codc. Chaptcr 9.12. and tAe Hcalth and SaCetY
�. Section 25532(a)? All roofs shall be inspected prior to any roofing material being installed.
� �� If a roof is installed without first obtaining an inspection, I agree to remove •
Will thc applicant or fuwrc building occupant usc eyuipmcn� or dcviccs �vhich
cmit haiardous air contaminanls az dcfincd ny the say Arca Air Quality Manascm��� all ReW 17 8teilalS fOL IIISpeC*10[l.
District? � .
❑ Ycs �
I havc rcad the Iwardcws ma�erials rcquirements undcr Chap�cr6.95 o(�he Ca1iCw-
nia Hcalih & Safcry Codc. Secuons 25505, 25533 and Z5534.1 undcrstand that iCUx 6uildinb
docs no� currcntly havc a tcnan4 that it is my responsibility to noe(y thc occupant of �he Date
myuiremc whichmuu,bem�tpciortois_ �ancc= Signature ofApplicant —
,��� w p�q� — d��� O All roof coverings to be Class "B" or better
Owncr or authori agcnt �a�