07110174 CITY OF CUPERTINO �
BUiLDING DIVISION PERMIT 4 *���������������� «
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PERMIT NO.
eu����yc�¢o.�ES�:ORTE MADER.A LN TIMOTHY MCAULIFF 07110174 .
1 b.5
., PEIZZMTI' LSSUE DATE
OWNER'S NAME:
MILLER DAVID J A CYN L 5883 EL DORI DR � 11/30/2007
SAMTARY NO. CONTROL NO.
)NE:
(408) 4�9-31�1
BUIC.DING PERMCC INFO
ARCHITECi/ENGINEER: gLpG ELECT PLUMB MECH
� 0 0 �
u O p LICENSED CONTRACI'OR'S DECLARATION JOU DCSCiIptlOfl
� V C I hcrcby �rm that I am lixnscd undcr provisions of Chapicr 9(wmmcncing
_z� withSccdon7000)ofDivision3ofUrcBusincssandProfcssionsCodc,andmyliccnscis COPPER RE-PIPE & DBLE-PANE WINDOW FM SINGLE PANE
�� y in full force and cf tect
� � Licenac Clus Lic. N
i •• DaIC ConUaclor
3 �"' ARCHiIECI'S DECLARATION
,� �< t undcrstanJ my plans shail be used as public rccords
�qU
4 p y Liccnsed Prufcssional
y � OWNER-BUILDER DECLARATION
I hcrcby alTirm that I am excmpt Gum �hc Con�rsttor's Liccnx Law for Uic
� ` � ra
p O follawing rcason. (Scction 7031.5, Busincss and Profcssions Ca1c: Any city or county
K$� which rcquiccs a pcmiit to conswct, alur, improvc. dcmolish, ar �epuir any swcwcc
n—�, �,
rior w i�s issuancc, also rcquims thc applicant for such permit io fik a signcd stamment Valuation
� _ � that he is liccnscd pucwant to thc pmvisiona of thc Conuactar's Liccnsc Law (Chaptcr 9 Sq. Ft. Floor ea $15 0 0 0
y t- �(commencing wiU� Section 7000) of Division 3 n( Ihe Business and Profcuions Code) or
y �.. that he is exempt the�efrom and tAe bssis far We alleged eumpdon. Any violatian oC
Secuon 7031.3 by a�ry applicant [a a permit subjecu ihe applicant W a civil penalty of 3 2 6 4 5 0 3 2!°� Number Oeeupancy Type
not mote than five hundmd dollus (SSOOZ
� I. as awner o[ tlie propcty. ar my employees with wagea as �he'v sok compensation,
willdotheworkendihestmctureisnotintendedorotfecedforsslc(Sec. Required Inspections
and Profasiona Cade: The Canuacwr's Lianse L.aw dacs not apply m an owne� of
property who builds or improves �hercon, and who doos such wort himu![or through his
own emplayces. Pmvidcd ihat such improvementa are not intended or oRered for sale. U.
however, the building or improvement is sotd wi�hin aie year ut compkuon, the ownu-
builder will haw the burdao o[ peoving U�ai he did not build or improvc [or pu�poae of
saleJ.
{� I. u awna o[ the property. am acclusively convacting wi�h littnsed conuactors w
lronstru�y lhe p�oject (Sec. 7044. Business and Professions Code:) The Coavacmr'a Li-
cense Law does not spply �n an rnwner of propeny w6o builds or improves Weieon, and ,
who conuacu for such projecis with a rnnuutor(s) licensed pursuant to the Convactofs
Litense Law.
❑ I am uem undu Sec. , B 8 P C far this rcason
Owur Di� / ' �
ER'S COM SATION DECLARATION
I hereby affirtn under penalty o[ perjury one af the tollowing declantions:
„ I hsve and will mainuin a Ccrtificate oC Conaem to self-insum for Workers Compen-
mrion, as pcovidcd for by Section 3700 of the Iabor Code. [or the performancc ot the
worlc for which ihis pertnit is issued.
❑ I havc and wiU msintain Worker's Compensation Insurance, as requited 6y Scction .
3700 0( �he Labor Code, Cor the pedormancc of Ihe work for wdich ihu p¢rmit ls iuued.
My Workefs Compenaation Luucance arsier and Poliry number ue:
Grria: Poliry No.:
CERTIFICATE OF EXEMPITON FROM WORKERS'
COMPENSATION INSURANCE
(Chis section necd not 6c compleicd if the permit is for anc hundred dotlars (S I00)
or Icss.)
I cenify that in �hc performancc of Ihc work for which �his permit is issucd, l shall nat
employ any person in any manne as bccomc b' t to the Worlccrs' Compensation
Laws oC Cslifom' tc �
Applicant
NUI7CE 7'O APPL[CA , aMr making �u Ccrtifca�c of FaccmpGon, you shoulJ
bccane subjcct to �hc Wo s Compensation provisions of ihc Labor Codc. you muu
� O fortNwilh comply wilh such provisions or this pccmit shall bc dcemcd tcvoked.
� �"� CONSTRUC170N LENDING AGENCY
[� ►�-� I hcrcby a�rm Wat ihece ia a constcuction Icnding agcncy Cor ihc perCortnancc uf .
�� ihc work for which.this permit is iuued (Scc. 3097, Civ. C.)
W Q l.endcr's Nvnc
� z Lender's Address _
V � � ttrti[Y ihat I have rcad dus applicuion and sutc thu thc abow informatiun is
w�"' cortcc� I a;ree w comply wiih all city md county oNinances and sta�e laws celating w
� U building consuuction, and he�cby authoria rcprcsenutivcs of ihis city w enter upon We
� W ahovc-mcnGoned propcny [ar inspenion pur{wses.
a (Wc) agra to save, indcmnify and keep ham�less the City o! Cupertino against
i „F„� � IiabiliUa, judgmcn�s, costs and expenscs which may in any way acccuc against said City /�
(� z in consequence of IAc granting oC Utis permi4 DaIE � J��
►"" APPLICAN'I' UNDERSTANDS AND WILL COMPLY WITH ALL NON-PO1NT Issued b ��:
SOU REGULATI S. Q
,c�� � 6 �� Re-roofs �!�
Signuuro of ApplicanVConuacar �°� T of l toof
HAZARDOUS MATERIALS DISCLOSURE }�Pe
�111he applicant or fuwrc building occupant storc or handlc ha•rardous matcrial
as defincd by �he Cupertino Municipal Codc. Chap�cr 9.12. and �he Hcalth and SaCety
c«� Sec�ion 25532(a)? All roof: shall be inspected prior to any roofing material being installed.
� Ycs �lo
wll ihc applicant or fuwrc building occupant usc equipment or Jevices whieh
If a roof is installed without first obtaining an inspection, I agree to remove
it harardous air conuminanu u dcfincd by the Bay Arca Air Qualiry Managcmcn� all new rnaterials for inspection.
JISItICI�
❑ Ya I�N� �
1 havc rcad U�e hvardaus maicrials requiremcnts undcr Chaptcr 6.95 of ihc Califor- C/7 ���� �� ���//���'" _ V �j)
nia Hcalth & SafcryCadc, Sectians 25505.25533 anc125534.1 undcrsund that if ilu building � /� �./ ���
does not curtcn�ly have a tenant, Wat u u my responsibiliry w noufy thc occupam of �he
rcyuiremcn�� ichmusibcme artoi uancco �'` r�8�aro����r. Signatur�: licant Date
7�� �� f� oa � Z- All roof coverings to be Class "B" or better
Owncr or awhor'vcd agc