04060011 CITY OF CUPERTINO ••
BUILDING DIVISION PERNO CONTRACT�O' R�INE,ORM .N *:
BUILDING ADDRESS: PERMIT NO04'060 0 11
OWNER'S NAME: PERMIT ISSUBDATE
CHINESE CHURCH N CHRTRT 1 .12
E: SANITARY NO. CONTROL NO.
RIF
ARCHITECTIENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
Lipp LICENSED CONTRACTOR'S DECLARATION O O O O
Y I k y rrrr IMI I am lieenxd umkr provisions of Chalncr 9(commencing Job Description
ez with Sections )af Division3ofthc Busi and profession.Code,and my license is
1^LIa inrallra az9 DEMOLISH INTERIOR OR CHURCH
"i Liccnx CI Lk.g
E= Dam Conmc
££ ARCHITECT'S D8C6,R_AYr0Xa
I understand my plans shell W used as public records
w
et; Lkemed professional
OWNER-BUILDER DECLARATION
I Mxhy affirm that I am exempt from the Cenlactors License,Law for the
p o following reason.(Section]ID 1.3,Business in Profession Cade:Any city or covnry
K$E which".I.a Permit Ip com mum.alcor,improve,demolish,m repair any...tort
prior W its issuance.also requires Ne applum,for such Pereniuo file a sighedsmemenl
that he is licensed pursuant to Nc provisions of Ne Conlrxtor's lictnx Law(Charter 9 Sq. Ft. Floor Area Valuation
z'0 (commencing with Section 7")at Division 3 of NC Business and Professions Code)or
,;9 Nat he is exempt Nemfmm and the bast for rise alleged exemption.Any violation of or�sk�p�v
SCCIlon 9031.5 by any applicant for objects bjects Ne applicant to a civil penally of {N1VWUWDr��
nes roam Our me hundred delta,.($500). Occupancy Type
I,uownerof Nepmperty,mmyemploycawiNwaguml kwlccompensation,
will do Newosk.and Ne swmme Is not inended.,offered forsale(Sec.]OCC,Business
The and Profession Code:TConuxm s License law does nut apply m an owner of Required Inspections
property who builds sir improves thereon.and who does such work himsel f or through his
own employees.provided Oaauch improvememart notinrerbed oroffemd forsale.If.
however,the building or"improvement is sold within one year of completion.the owner-
Milder will have the Widen of proving Nat he did not Wild or improve for puspou of
sale.).
❑1,as owner of the property,am exclusively contracting with licensed contractors to
construct the projem(Sec.]OCC.Business and Poeformoa Code:)The Como.orh Li.
come law does not apply W an owner of property who Milds or improves Nemon.and \�.(
who contracts for such projects with a eomrxtor(s)licensed pursuant to Ne Contractor's \
Licence Law.
❑lamaxemplunder Sec. ,Bk PCfordusmaon
Owner Dam
WORKERS COMPENSATION DECLARATION
I Mrtby affirm under pcaW ly of perjury one of the following declaustimer
Owner
will maintain a Cediframof Comenuoulf-imum for Workefs Compen.
"tion.as provided for by Section 3100 of the Labor Code,for the Performance of One
work for which Nis permit is issued.
❑I have and will maintain Workers Compensation Imuran¢,as required by Section
37M of the labor Code,for the performance of the work for which this permit is issued. . .
My We,, a Compeomtion In ties..coria sod Policy//number art:
Cartier. 1 A Policy NoA iso
CE,
OF EJ Pf10N FR ORKFRS•
COMPENSATION INSURA CE
(Tru ration reed nmlbe canplcmd if the permit Is fmnne hundred dmllan(SIOO7
or Mea)
I certify Nm in the performance of the work for which this Permit is issued,I shall not
employ any person in any mannerm u m become subject to the Worketf Compensation
Laws of California.Dae
Applicant
NOTICE TO APPLICANT.If,after making this Certificate of Exemption,you should
become subject In Ne Worker's Compensation previsions of the Labor Code.ynu must
.J2 forthwith comply with such provision or this Permit shall x deemed revoked.
Z O CONSTRUCTION LENDING AGENCY
1-+ I bereby affirm Nat Neu is a eomvuctinn lending agency for the perfornsucc of
C' Ne work for which this permit is issued(Sec.3097,Civ.C.)
A Lcndc3Name
0.
0.Z, Londees Address
U 0 I cemiry Nat 1 have read this application and sum Na Ne aWao information is
i. P correct I agree to comply with all city and county ordinances and sate laws miming W
0 U building construction,and hereby authorise representatives of this city to enter upon theabove-mentioned Property for inspection purposes.
F6. (We)agree to ave,indemnify and keep harmless the City of Cupertino against
w y liabilities,judgments,cos¢and expemcs which may in any way accrue against mid City
U z mconsequence oNDERSTgranting eflhiND WIa Issued by. Date
^' SOURCA ST AND COMPLY WITH ALL NO
SOURCE RE LATONS.
Re-roofs
Signuore of UCon for Dam
HAZARDOUS MATERIALS DISCLOSURE Type of Roof
Will Ne applicant or forme Wilding occupant alert orhanule haallous maerlal
a defined by the Cupertino Municipal Code.Chapter 9.11,and the Health and Safety
'joijode,s❑tioYes EK-__n 25532(aH All roofs shall be inspected prior to any roofing material being installed.
Will thea applicator or future building occupant use a If a roof is installed without first obtainingan inspection,I agree to remove
PP C P a Air
p
harardnus air contaminants a dcfncJ by Nc Bay Arca Air Qualisy Management all new materials for inspection.
isvicsP
❑Yes nir
1 ban read the Weaduuamaerials requirements undcrChapmr6.95 of IW Califor.
nst H.10&Safety Code.Seeti=ts M5.M533md25534.lundcr dthmiftbe Wilding
does note hare a=an IMI it is my mapamihibly W notify the occupant of dm
rtquirementawh h us I prior W issuanm of a Cestifcam of Occupancy.
Signature of Applicant Date
o r 6.1hoo,odagcm Dam All roof coverings to be Class "B"or better