05020122 CITY OF CUPERTINOs* v^* ^f'-
BUILDING DIVISION PERMIT 'dCONTRA TOkaINFORMATION �M
BUILDING ADDRESS: DAVID DELGADO PERMITNQ5020I22
10-ASS RoNNY ng
OWNER'S NAME: FERMITLSSUEDATE
DAVID DELGADO
.NE: SANITARY N0. CONTROL 10.
ARCHITECT/ENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
Attoo LICENSED CONTRACTOR'S DECLARATION JobDescri I3Gn
WC 1 hereby affirm On(I an licensed under pmvuiom of Chapter 9(commencing P
U with Section Illtlll)of Division 3 of Ne Business and Professions Code,and my license is
infull farm Licenseand erra'' REVISION-REDUCING SQ. FOOTAGE TO 275 -
p�?
Dam Contractor FROM 4301 ORIG PERMIT 04090055
ARCHMECTS DECLARATION
9'0i< Iunderstand myplans slueodied as public records IN HOUSE ONLY-NO NEW PERMIT
yU
p Licensed Prvfcssionel
` g OWNER-BUILDER DECLARATION
aF 1 hereby affirm Nal 1 am exempt from die Contractor's License Law for the
p o following reason.(Section 9131.5,Business and Professors;Code:Any city or county
which acquires a Permit to ennsuuct,after,improve,demolish,tor nepair any structure
'd$ prior N its Issuance.also requires the applicant for such Permit to file a signed slatemenl
that he is licensed pursuant o the provisions of the Conuacsori License Law(Chaptcr9 Sq.Ft. Floor Area - Valuation
(commencing with Section 9000)of Division 3 of the Bonn=and Profeuians Codc)or
y $ that he u exempt therefrom and dm basis for the alleged c¢mplion.Any violation of $100000
Section 7031.5 by any applicmsfor a permit subjects to applicanna a civil penalty of APN Number Occupancy Type
nas mare Nan five hundred dollars(5500).
❑1,as owner of the property,or my employees with wages as their sole compensation,
will do the work,and the swcmre u not intended of oRerad for We(See.7064,Business
and Profetiov Cada:The Coneacmri License law does not appy N an owner or Required Inspections
property who Wildsorimprmes thereon,andwho doessuch.,it Mmeelfor through his
own employers,provided Nat inch imprommen s arc not intended oroRered forside.If.
however,the building or improvement is sold within one your o(complcuon.Ne owneo-
builder will have Or burden of proving Nat he did not Wild or improve for purpose of
sslc.). /
❑1.as owner of the pmpmy,.B exclusively contracting with licensed ronwctors i \�•C•J�
amor La thees out (Seco...Business and Professions Code:)The Contractorind f� -
cemc taw docs not apply to an owner or property who Wild.por imptovft thmeon,and V g�
who concocts for such DroKcu with a contracmr(s)liamed pursuant to the CanuaclaR
Lkcntt Law.
�'am c ptu .BgaPCfmthismason
toner ,'�TYI" "��L'a"N�7 Data 02�Z
WORKERS COMPENSATION DECLARATION
Rnn
1 hereby auddar penalty of'do,
orator
rc of the following declarations:
❑1 haw and will mountain a Cenifate,of Concent to self-insum for Workefa Compere
cation,as provided for by Section 3700 of the labor Code,for the performance of Or
work for which his permit is issued.
71 1 have and will maintain Worker's Compensation Insurance,as required by Section
37W of the tabor Code,for Ne performance of the work for which this permit is issued.
My Workers Compensation insurance amicr and Policy number arc:
Carrier Policy No.:
CERTIFICATE OF EK EM MON FROM WORKERS'
COMPENSATION INSURANCE
(This section need not W completed if the permit is farone hundred dollars(SIM)
or lass.
1 certify that in Ne performance of the work for which this pmmis is issued.I shall not
employ any' gawnaf m u m oeomc subjcn m the Worter5 Compensation
Laws of Cat quo so b,
Applicant
NOTICE TO AP ICANr:If,after making this Certificate of Exemption,you should
become subject to the Workers Campcasation provisions of the Ichor Coe,you must
.JO forthwith comply with such provisions or this permit shall o deemedreward.
Z " CONMUC71ON LENDING AGENCY
Iherchy M.Nat than is acoatructom lending sgcuy,or Or perfmiana of
a the work for which this permit is issued(Sec.309'1,Ch,C.)
W
Untie'a Name
z Lem'.Address
U t7 1 acnify that t ban mad this application and state that the about information is
L4 F, correct.I agree to comply with all city and county ordinances and sum laws relating to
0 U building construction,and hereby authorirs mpresentatims of this city in enter upon Ne
rw move-menumm property for inspection purposes.
(•"4. (Wc)agree to saw,indemnify and keep hamsless the City of Cupertino itimmt
y
liabilities,judgments.costs and expenses which may in any way accrue against sod City
U in consequence or the Seaming of Nis Permit.
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT Issued by:9 Date
SOURFEi� A S.
d�L�d
T2` a
Signature ofApplicaor O2' Datm Re-roofs
HAZARDOUS
MATERIALS DISCLOSURE Type of Roof
Will the a CuP ntma(muni Wilding occupant nom or ahandlend in h ramous material
as d.,Sed io Nc Cupertino Municipal Code,Chapter 9.13,and rite Health arta Safety
Cod.,Semon 25532(an
❑Yea ❑Na All roofs shall be inspected prior to any roofing material being installed.
Will the applicant or future building occupant use equipment or devices which If a roof is installed without first obtaining an inspection,I agree to remove
it hourdous air contaminants as Urined by the Bay Area Air Quality Management all new materials for inspection.
Dieoict?
❑Yes 0 N
1 have mal the Waamsms materials requirements under Chapter 6.95 of Ne Califor.
ma Health A Safcty Coda,Samems 25515.25533 and 25534.1 umkrctand Of it the building
does not currcn0y have a mnan.Out it is my responsibility m not I the occupant of the
ouluxur, qrs bio xmmPdormiasuaneeofacrrefieateorampancy. Signature of Applicant Date
ltr�a'ry U2- 2.0 -U.j .
Owner or ambonwd+gent Data All roof coverings to be Class 'B"or better
r