07080259 CITY OF CUPERTINO ' � (�
BUILDINC DIVISION pERNIIT ����������"'������ '
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PERMIT NO.
BUIL �� r � c 1 n 8� HAZELBROOK DR TBD T�� BE DETERMINED 07080259 .
OWNER'S NAME: �����
� 11/21/2007
PHONE: SANiTARY NO. CONIROL NO.
2CHTIEC[7ENGiNEER:
BUfLDINGPERMITINFO
BLDG EI,ECI' PLUMB MECH
� � 0 �
u O p LICENSED CONTRACI'OR'S DECLARATION
� I hcrcby afficm tAa� 1 am licenxd undcr provisions of Chaptcr 9(commencing Job Description
� z� wi�h Scction 7000) of Diviaon 3 of ihc Business and Pro[cssions Codc, and my Iiccnsc is S F DWL 3 7 9 3 S Q. FT . NEW L I V I NG 81310 5. 0 0
�� a in full focce and cftec�
;�� u���� c,us ��.• GARAGE � 9 2 X 5 6. 3 8 3 3 3 7 6. 9 6
=`' o ��'` °atc pRCH[TECI'S AECLARATION PORCH 19 X 3 8. 51 7 31 . 6 9
;�< I undcrsunJ my plans shall bc uscd u public records
a
4 O y Liccnsed Rufescional
n ,� 3 OWNER-BUILDER DECI.ARA'CION
� `� 1 hcrcby afGrm that 1 am cxcmpt Gum 1hc Conuactor's Liccnsc Law for 1hc
y p O following reuon. (Scction 7031.5, Busincss and Profcssions Cafc: Any city or rnun�y
�$ Pi which requims a pcm�it �o rnnswc4 aitcr. improvc. dcmolich. cu iepair any swcwm
y Z y prior b ils issuancc, aLt� rcquims the applicanl for such pertnit �o filc a signed summent
< that hc is IiccnscJ pursuanl to thc pmvisiona of ihc Conuactars Liccnsc Law (CAsptcr 9 Sq. Ft. Floor Area Valuation
y ��(commencing with Sccdon 7000) of Division 3 of Ihc Busincss and Profcuiona Codc) or $ 8 4 7 213
y �.. thai he is exempt theretrom and the basis [or �he sllcgcd exempdon. Any vioiaGon of
Section 703L3 by a�ry applicant for a permit subjecu the applicant to a civil penalty of 3 2 6 2 8 0 4 a� Number Occupancy Type
not more tlun fiw hundted dollars (5500).
❑ i. as owner of tt�e property, a my employcea with wages u the'v sole compenaadon,
will do ihe wock, and the suuawe is not intended or ofCered for aa� (Sa. 7044. Businesa Re uired Ins ections
end Professions Code: The Conuactor's License Law dors not apply to an ownec of Q P
property who builda or improves thercon, and who daes such wmk himseltor tlwugh his
own employces, provided ihat such improvements am not imm�ded or oRered for ssle. I[.
however, the building or improvement ia sold within ane yesr oC compkuon, the owner-
builder will have Uu burden oC proving tha� he did not build w improvc [or purpose of
sakJ.
❑ I, u owner of ehe property, am eacclusivcly conuaMing ari�h lianaed conuscmrs w
conatraM ihe projen (Sec. 7044. Business and Profrssions Cade:) The Coatractor's Li-
cente Law docs oo� apply �o an owner o( propeny w6o builds or improvrs the�eon, and ,
who conuacts for such pmjects with a conuactor(s) licensed pursuant W ihe Convutor's
Licenae Law.
❑ I am exempt under See, , B dc P C for this reLwn
owner
""'"'""%' �� Date <<�Z6 0
�70R� O SA'I70N DECLARATION
I hercby affirm under penalty of perjury rn�e af the folbwing declaraGons:
❑ I hsve and will mainuin a CertiGcam of Consem to self-insum for Workcr's Compen-
eation, as providcd for by Section 3700 of the I,6or Code, for ihe performana of thc
xk for which this permit is issued.
�] I have and will maintain Wwkcr's Compensation Insunncc, az tcquired by Scction
3700 of thc Labor Codc, Cor the pcdormance of �he work for which this permit is issued.
My Workers CompenaaGon lnsurance carticr and Poliry number are:
Grtier: Policy No.:
CERTIFICATE OF EXEMPCION FROM WORKERS'
COMPENSA770NINSURANCE •
(77iis section necd not bc compktcd i( t4e permit is far onc hundred dollua (S 100)
or Icsa) •
I cenify �hat in thc perto�mancc of the work far which ihis permit is issucd I shall not
employ any person in any manner so u m become subject to the Worlcers' Com nsation
Laws ot Califomia Datc
Appiicant
NOTICE TO APPLICA ; a(icr malung �s Ccrtiticam of F�ccmption, you should
becane subjcct to lhc Worlccr'a Compensstion provisions of the Lalwr Cadc, you muu
� O forthwith comply with such provisions or this pccmil shall 6c dccmed revokcd.
z ""' CONSfRUCTION LENDING AGENCY
[- � I Ixreby alGrtn Uut there ia a co�tcucdnn Icnding agcncy far thc perlarmancc u!
p�., � ihc work for which this permit is issucd (Scc. 3097, Civ. C.)
W� Q I.ondcr's Namc ^
a z Lende�s Address
V 0 1 ccrtifY ihat 1 havc rcad ihis application and sum ihst thc abovc info�matiun is
w�"' cortcc� I sgrce w comply wi�h ill city and county onfinances and s�ate laws eelaung w
� U building consvuction, and hereby auchorin ccpreumaGvcs of this ciry to cn�cr upon �he
above-mcnuo�d propeny for inspec�ion purposes.
�" W (We) agrce �o save, indcmniFy and kecp harmless the City of Cupertino against �'
�,H„� � liabilities, judgmcnis, cos�t and eacpensca w6ich may in any way ucn�c agains� eaid City
V z in consequence oC ihe gnnting af this permi� /
�"� APPUCANT UNDERSTANDS AND W1LL COMPLY WITH ALL NON-POINT Issued by: Date / 2 G
SOURCE REGUI.ATI�,Q1�18.' ✓ �
"':��'� � �l ��' 7 Re-roofs iz�
Signuuce A canUContractor Dalc
HAZARDOUS MA7'ERIALS DISCLOSURE Ty]� Of R� )Of
`�. Will lhc appliant or futwc building occupant storc or handlc ha•rardous matcrial
u dcfincd by the Cupertino Municipai Code. Chapicr 9.12, and the Hcal�h and SaCcty
c� Scction 25532(a)? All roofs : hall be inspected prior to any roofing material being installed.
❑Ycs ❑No
�II thc applicant or future building occupant use cyuipmcnt or Jevices which
If a roof i: installed without first obtaining an inspection, I agree to remove
emit hai.udous air comaminanu u �lcfincd by thc Bay Area Air Qualily Managcmcm all new m; �terials for inspection.
District?
DYcs ❑No
1 havc rca�i �he hvardau maicrials requiremcn�s undcr Chap�cr 695 of Uu Califor-
nia Eka1tA dc Safcry Cadc, Scx�ions 25505.25533 anc125534. I undcistand �hat iCthe huilding
docs not curten�y havc a tenan4 wat it ia my responsibili�y w notify �he accupent nf �he
�,,;�,,,�„�Wn;�,, «�o��;u��orec�,;r,��oro�� Signature �fApplicant Date
� j ���� 7 All roof coverings to be Class "B" or better
O�or authorizcd agcni ���