04010037 CITY OF CUPEWHNO
BUILDING DIVISION PERMIT CONTRACT•O]R INFORMATION
PUILDING ADDRESS: """"04010037
ERMITN004010037
NERS NAME: PERMIT MUE DATE
C
nzl
ONE: SANITARY NO. ONTROL NO.
ARCHITECTIENGINEER: BUILDING PERMITINFO
BLDG ELECT PWMB MECH
f� 0 l�
u o o LICENSED CONTRACTOR'S DECLARATION Job Description
rk U U I hereby affirm that I am licemed under Provisions of Chapter 9(commencing p
^� with Section or Division 3 of NC Business and Professions Code,and my license is
d in full force and eft«g
ii3t ?License Class Lic.0 REVISION--IN HOUSE USE ONLY
C—o Dam Contractor NO NEW PERMIT/ORIG. #03100019
p;m ARCHITECTS DECLARATION
C< 1 undersand my plans shall he bond as public records
JyU
Licensed Pmressional
S OWNER BUILDER DECLARATION
1 hereby affirm that 1 am exempt from the Contractor's License Law for the
p o following reason.(Section 7031.5.Business and Pmre>siuu Code:Any city Of county
'nil m which requires a pmmit to consumer,alter,improve.demolish,or repair any structure
Prior I() issuance.also requires the applicantfor such Permit to rile a signed statement
pprem the,Wisliccnmdpursuant1.she powifiomsortieCmdurauriliensLaw(Chapter9 Sq. Ft.Floor Area Valuation
$40'
Y� (commencing with Section 7")of Division 3 of the Business and Professions Code)or
a. Net he is exempt therefrom and the oasis for due alleged exemption.Any violation of
Section 7031.5 by any applicant for a permit subjects the applicant to a civil Penalty of APNNumber OOCU
not more man five hundred dollars(SSW). P ane Y Type
01,u owner()fthe protanny.or my employes with wages as their sok compensation, 35923018 . 00
will do the work and dre sWctum is not immndcd or offered for sale(See 7061,Ruffians
said Pmressmns Code:The Conductors Lkcnse Law does not apply to an owner of Required Inspections
pmpeny who builds or improves menton,and who does such work himself or through his
own employees,provided that such improvements an,not intended oroffered forsak.If.
however.due building or improvement is sold within one year of completion,the owner.
builder will have the burden of proving mar,he did not Wild or improve for purpose of
talc.).
cad1,nownerof Uteproperty,,musinesand conuaning with licensedonnmor's to
come Lo the project(Sec.o a x,Business and Profcssions Code)TheContractor'sChar tori Li-
come law docs not apply lean owner of propcny who Wilds or improves thereon,and
who conbacu for such projects with a contnnor(s)littnud pursuant to IW Cankeaora
[3 Ise taw.
❑ am exempt under e. ,B&PCfor this..on
nor Date I I O
NSAI gECLARATION
I hereby affirm underp.try or perjury() following discussions:
1 ban and will maintain a Cenifcam of Consent to self-insure for Worker's Crimper-
nation u pm,i&d for by Section 3700 of the Labor Code.for the perronnanm or be
work for which this permit is issued.
❑1 have and will maintain Wokcri Cc mpawtion hste urs,u rcquiondi by Section
3700 of the laWr Code,for the performantt of me work for which this permit is issued.
My Wofkcls Compensation Insurance carries and Policy num her are:
Cartier, Policy No.: _
CERTIFICATE OF EXEM PTION FROM WORK ERS'
COMPENSATION INSURANCE
(This section need not W cm011mad if me Permit is foronc hundred dollars(5100)
of k5i)
1 cenify that in lW performance of the work for which this Permit is issued.I shall no
employ any person in any manner an as m become subject to the Workeri Compensation
Laws of California.Date
Applicant
NOTICE TO APPLICANT:.If,after making this Couricale or Enandim.you should
become subject to the Workers Compensation provision of One la Wr Code,you most
.JO forthwith comply with such provisions or this Permit shall W deemed revoked.
ZDs CONSTRUCTION LENDING AGENCY
'e+ Ihe¢Ay infrmmu there is a construction lending agency for the Performance of
6L' the work for which this permit is issued(Sec.3097,Civ.C.)
leader's Name
z Lcndcr's Address
V Q I«oily that 1 have read this application and form that the aWw information is
ls. fir torten,l agree to comply with all city and county ordinances and sure laws relating to
�(J building construction.and hereby induction representative,of this city to enter upon to
,Weretic yo ra rnoPeny rot epeoien inurrawhich ms
H y (We)agree to save,indemnify and keep harmless the City of Cupertino against
(ZIZ liabilitia.mac fthecostsang of this wMCM1 they in any way accrue against said City /
r..7 z A APPLICANT
ND flooding this a mit.
^ APPLICANT UND STANDS AND WIL COMPLY WITH ALL NON-POINT Issued by: Date D
SOURCE REG
/ Re-roofs
nates ¢an onbactot Dato
HAZARDGSISMATERIAISDISCLO Type of Roof
Will me applicant or fours building occupant store or handle harardous material
u defied by the CuPenim Municipal Code.Chapter 9.12,and the Hcalts and Safety
ode,Scetim 25532(1)? //
c Yca t/1- - All roofs shall be inspected prior to any roofing material being installed.
Will the.applicant or future building reeb ant use a If a roof is installed without first obtaining an inspection,I agree to remove
PP B P a Air Qu or dineric.which g
7ni�H.Iffi&SgetyC�.S.I..25505,M533.d25534.1..Mrs.dmwitft
M1andnuf air a()ntammantsdefnea by me bay Area Air Quality Management all new materials for inspection.
1[1?
O Yes No
I have mad the hanNrNs materials mPOmmcns umdc1Chapkr6.95 of IW Califor-
maiflM Wilding
nol currently have lento,that n is my responsibility to notify Ilm o:cupml or the
immcnu which m m()issame r,eemfe,m()ria epporcy. Signature of Applicant Dale
lJ/
Ocr car atop All roof coverings to be Class "B" or better