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CITY OF CUPERTINO
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BUILDINCDIVISION PERMIT
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BUILDING ADDRESS:
10314 MIRA VISTA RD
HOLDER INC DBA ABLE GLASS
PERMIT NO.
08020153
NER'S NAME:
PERNIM LSSUEDATE
1129 RICHARD AVE
02/25/2008
PHONE:
SANITARY NO. CONTROL NO.
(408)739-8829:
ARCHITECnENGINEER: -
-
BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
LICENSED CONTRACTOR'S DECLARATION
Job Description
thereby affrmi that 1 was Became under provisions of Chapter 9 (commencing
with section 7") efDivision 3 ofthe Business; and Professions Code, and my license is
REPLC EXSTNG SNGL PANE WNDW W/NEW VINYL DBLE
in full force and at.• 0
we class Lk.N
PANES
•
Dau Contractor
AEL TS DECLARATI N
ENRGY EFF WNDWS
1 undersand my planss shell Mdl be used u public mrc"da
,
Licensed Pmfessiond
OWNER -BUILDER Ce ON
m Conti License taw for the
1 hereby affirm I am exempt from the Contractor's
Code:A
following moan. an Bun•..s and oss Any city m county
construct, rte, de h.o
which require a permit m cortswc4 elan improve, demnlixh, or repair any structure:
permit
• prior to its issuance, alw requires the applicant forsuch Permit to file &signed statement
to of the Cmurectur'a Licence law(Chapter 9
Sq Floor AIea
Valuation
that he is ficcamd pursuant the praibdam
-Ft.
I(commencing with Section 7")dDivision3oftheBunnesaundProfessinnsCode)ter
$7250
Nal he is exempt thmefmm and Me basis for the alleged eumption. Any violation of
�
Occupancy Type
Section 70113 by wry applicant for a permit subjects the applumt in a civil penalty ofNumber
not more Man Bw hundred dollars (M),
355702022,`
0 Lumsecaroftheproprsly, ormyemployces with wagesuthetr role eampenuUon,
Required Inspections
e
will do the werkmd thesNatute is nothunded or offered forsake (Sm. 7094, Business
and Professions Cade: The Consumes License law dean rot apply m m owner of
q p
property who builds car i m prows Nercon, and who does such work hmuelf or though his
ownemployva, provided thmanch Improwmants am not intended oro@rod (mark. IL
hansom. Ne building or improv ren is sold within au year of completion, the owner.
builder will have tie harden of proving that he did an build or impmw for purpose of
ale.).
0 1, as &war of the promay, am exclusimly contracting with licensed cam rsencea In
mnswct the project (Sec. 7014, Summers aM Professions Cade:) The Contractor's Lt -
cove Law does not apply u an owner of property who builds or impmw& Nemoo, and
who common; for such pmjeets with a contamor(s) licensed puavanl m the Combectofs
License Law.
❑ l am "am" ' 3"C (or Nis naa"me
mer Data Z. zro
....
WORKER'S COMPENSATION DECLARATION
I hereby al0rm under penalty of perjury =of the following declarations:
❑ Ihamand MIlmalnuinaCen riiamofConunttowlf-InsumforWarker'sCompen-
salion, u provided for by Section 3700 of Ne labor Code, for the performance of the
wok for which this parent is issued.
0 I haw and will maintain Worker's Compression Insurance, as required by Section
3700of Ne Labor Cada, for the performance of Ne work for which this permit is Wesel,
My Worker' Cotope..due Msec. artier and Policy number are:
Carrier. �.gap� i Polley Na.: GF9g9r'fZIL
CERTIFI ,ATE OF MEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(Ihasution need suite completed if Ili permit is forane hundred dollars ($100)
or leu)
I certify, Met in the performance of the work for which this permit is issued. I shall not
employ any person in any manuran as m become subject in the Workers' Compensation
Laws of califamia Data
Applicant
NOTICE TO APPLICANT. IL afar making this Certificate of Exemption, you should
become subject in Ne Worker's compensation previsions of also tabor Cade, you must
famhwith comply with such pmvimOrl"this permit shell W dcamed revoked.
)
CONSTRUCTION LENDING AGENCY
1 hereby affirm the More its construction lending agency for the perfamtance of
' the work for which Nis permit is, issued (Sec. 3097, Civ. C.)
'
lander'. Name
lander'. Address
1 curtly Nu I haw road this application and sale Mal the show informadun is
• correct. I agree to comply with all city and county ordinances and sou laws misting to
building construction, and hereby authodu repuuntstims, of this city to enter upon the
above-mentioned properly for Inspection purposes.
(We) agree to taw, indemnify and keep hmmkss the City of Cupertino against
j liabilities, judgmemu,costs and expense which may in any way acerae against said City
in eOMousc ee of 1M granting of this permit.
• APPLICANT UND1@@@STANDS AND WILL COMPLY WITH ALL NON -POINT
Issued by: Date L
SOURCE REGNS.
Re -roofs
Type of Roof
Signature pplium/Comracmr Data
HAZARDOUS MATERIALS DISCLOSURE
Will Use applicant " future building scup rIstote or handle huadous material
as defined by Ne Cupertino Municipal Code. Chapter 9.13, and the Health and Safety
. Section 25532(&)7—/
C] you GTVo
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 Ne applicant or future building occupant use equipment or devices which
emit havadnus air contaminants u defined by Ne Bay Arca Air Quality Management
all new materials for inspection.
District?
CYes Qua'
n�materials mquimme es under Chmmr6.95 of the Califon.
1 haw mad the ha adu
meHealth h SarmyCode, Sourns 25505, 25533 and 25534.1 understood and ifNc Wilding
dao notcr.11y ha anent, that h u my responsibility m notify Ne Occupant of the
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