05030235CITY OF CUPERF No
BUILDING DIVISION PERMIT
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x3CONTRACTTOR INFORMA'CION.:;
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BUILDING ADDRF:
PERMIT N0.05030235
OWNER'S NAME:
PERMrT LS5UE DATE
L:
SANITARY ON OL NO.
ARCHITEC (ENGINEER:
BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
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LICENSED CONTRACTOR'S DECLARATION
Job Description
I hereby afftrm that l am licensed under previsions of Chapter 9 (commencing
P
With Section 2(X10) of Division 3 of the Business end Professions Ca o,Snd my license is
full force and ark°'
REVISION --IN HOUSE USE ONLY
License Class Lie.
Li
Date Contractor
NO NEW PERMIT ISSUED ORIG. #04060014
ARCHITECTS DECLARATION
1..&.land my plans Shall he used as public records
Licensed Professional
OWNER -BUILDER DECLARATION
1 hereby affirm thin I am exempt (firm she Comrecloh License Law for the
following mason. (Section 2001.5, Business and Professions Cale: Any city or county
'
which requires a permit to construct, alter, improve, demolish, or repair any structure
prior In in issuance, also requires the applicant for such permit to file a signed statement
Sq. Ft. Floor Area
Valuation
that he it licensed ninumtolbe prowlsion. of the Contractor's License Low (Chapter 9
$35
(commencing with Section ]WO) of Division 3 of the Business and Precessions Coda or
Nn he is exempt thertfrom and Ne basis for Ne alleged exemption. Any violation of
APN Number
Occupancy Type
Section 701.5 by any applicant for a Permit Subjects the applicant a civil penalty of
not more Nan five hundred Jolla. ($5(10).
35907010.00
O 1, as owner of the property, army employees with wain as their into compensation.
Required Inspections
Wilt do the work, and the structure is notimended proffered for sale (Sec. 2044, Business
and Professions Code: The Contrecmr'a License Law does not apply w an owner of
property who buildsor improves themon,and who doeuuch work himselfor through his
own employees, provided that such improvements rte not intended oroRered la Sale. If,
however, Ne building or improvement is sold within one year of completion, the owner.
builder will hove the burden of proving that he did nm build or Improve for puryose of
sok.).
O 1, as owner of the propcny, am exclusively contracting with licensed .."Co.. tp
construct the project (Sec. 21X4, Business and Professions Codeq The Contractor's Li.
�!V\
mom Law does not apply to in owner of propeny who Wilds or improves Ommen, and
who contracts for such projects with a contrector(0 licensed pursuant m the Conu¢IOYS
Licenae Lew.
O l am exempt under Sec. ,B& P C for this reason
nor Dow
WORKER'S COMPENSATION DECLARATION
I hereby arum under Penalty of perjury one of the following declarations:
O I him and will maintain a Certificate of Consent to self-insum for Workefi Compere
urian, as provided for by Section 37M of She Mbar Code, for the Performance of Ibe
work for which this Permit is issued.
O 1 have and will maintain Worker's Compensation Insurance, as required by Section
3200 0( Ne Labor Code, for the perfmmmec aide, work for which this permit is issued.
My Workers Compensation Insurance prier and Policy number art:
Cannc,: Policy No.: _
CERTIFICATE OF EKEMMON FROM WORKERS'
'
COMPENSATION INSURANCE
(This Section need not W completed If IM permit Is foram hundred dollars ($300)
,
or lcssJ
1 cenify that in the perfnrmence of the work for which this permit is issued. I shell net
employ any peraem in any manner an az In become subject to the Wofker5 eogr enaatlon
Laws o(Califofmia. Date
Applicant
NOTICE TO APPLICANT: If, after making this CoMfinew Of Exemption, you should
become Subject 10 the Worker's Compensation provisions or the Labor Code, you must
forthwith comply with such provisions or this Permit be deemed revoked.
CONSTRUCTION LENDING AGENCY
1 hereby Nn dire iso construction 30 lending Agency for Ode Performance of
which
thework lm which lM1is permit is issued (Sec. 3(X2, Civ. C.)
Name
lender's Address
I cenify that I have rad this application and show Net the above information is
I agree m comply with all city and county ordinances and state laws rclatingto
building construction, and hereby outhorin representatives Of his City to enwl Upon
&hove mentioned properly for inspection purposes.
(We) agree to eve, indemnify end keep harmless the City of Cupcnino against
liabilities.judgments, costs and expi which may In any way accrue against Said City
in consequence of the granting of this Permit.
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON -POINT
Issued by: Date
6kL
SOURCE REGULATIONS.
Re -roofs
Signature ofApplic&nVContractor Date
HAZARDOUS MATERIALS DISCLOSURE
Type of Roof
building Occupant or handle
Will the Applicant or future Occupant
r 9,1 Health and
as defined by the Cupertino Municipal Cuda Chapter 9.12, and the Hcellh end Safety
ni
Oodc, Section 25532(.)2
All roofs shall be inspected prior to any roofing material being installed.
[_1 yes ON.
If roof is installed without first obtaining an inspection, I agree to remove
Will the applicant or future building occupant use equipment or devices whicM1
emit haaardous air contaminants as defined by the Bay Arca Air Quality Management
all new materials for inspection.
District]
❑Yes ON.
I have mail the havNous materials requirements under Chapter 6.95 of the Califon
ria Health & Safety Code, Sections 25505.25533 and 25530 1 UnderstaM that i(tite Wilding
does not currently twee a tenant, that it is my maponsihility in And iy the Occupant of Use
mgairements which mug Lr met prior to transfer of Certificate of Occupancy.
Signature of Applicant Date
All roof coverings to be Class "B" or better
Owner in afthori ad agent Dale