05060151 CITY OF CUPERTINO ,awn
BUILDING DIVISION PERMIT CONTRACTOR INFORMATION
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BUILDINGADDRESS: BC ELECTRIC AKA LIFETIME PERMIT NO,05060151
ERSNAME PERMIT La5l3E DA'Z'E
END
PHONE: SANITARYN ONTROL NO.
ARCHITECT/ENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
0
LICENSED CONTRACTOR'S DECLARATION D lI n'R ry tl E Vtr�
O o❑ 1 hereby affirm that I am licensed under provisions of Chapter 9(commencing Job DESCrlptio .1 tlryryyy
iOied with Section'100q of Division 3 oftW Business and and Prafession Code.and my licchnc is b OG bad �a
in full force Lxar.Clsao°cff"` 7597/ ROLL MILL EQUIPMENT
Damnu Class ARCHITECTS DECLARA ION
16 zoos
sy rc1 understand my plans shall W used u public mcons;
DING
C Licensed Professional
3 OWNER-BUILDER DECLARATION
BUIL
1 hemb,afrom Nat 1 am exempt Tram um Cmancmfs License Law for the
n o following mason.(Section]IDES,Business and professions Code:My city or county
K m which parishes a permit m construct.alter,improve.dcmnliah,or repair any Structure
prior to its issuance.ales m,juireslheapplicanlforsuch permit w file asr,atd statement
-�i
that he is licensed purmam to the provision of the Contractor's License Law(Chapter 9 Sq.Ft.Floor Area Valuation
zt-0 (commencing with Seetion]OW)of Division 3 of the Bummor and Profeaainn Cute)or
that he b exempt therefrom and the bub for the alleged exemption.Any violation or
Section 7031.5 by any applicant for a permit subjects the applicant to a civil Penalty of 3A719O itler00 Occupancy Type
not mom than five hundred dollars(5500).
❑1,u asvner of the properly,or my employers with wage u Heir sole eompenuuon,
will do the work and theswclumis not intended or offered forsale(Sec.]Uas,Buxinue Required Inspections
and Professions Code:The Conusemfs License Law does not apply wan owner of q P
property who builds orimpmves thereon,and who doessuch work himselforthrough his
Own employees,provided that such improvements are notimande t oro@hid forsale.if,
however.Ne building or improvement is Sold within one year of completion.the owner.
Wilder will have Ne burden of proving that he did not bulb or improve for purpose or ;
sale.),
0 1,as Owner of tie property,am exclusively contracting with licensed contrarian to
construct Ne project(SCC.7W,Business and profeatiou Code:)The Contractor's Li.
cense law docs not apply to an owner of property who Wilds or Improves daemon.and ,r
who emorni for such pmjecu with a conuactor(s)licensed pursuant o Nc Commeto's
License Law.
0 1 am exempt under Sec .B&P C for NNS mason
sk r Due
WORKER'S COMPENSATION DECLARATION
1 hcmby affihm under penalty or perjury one of the following declarations:
I have and will maintain a Certificate of Consent m self-insum for Worker's Camper.
tion,a provided for by Section 3700 of the labor Code,for thd performance of the
work for which this permit is issued.
0 I have and will maintain Worker's Compensation Insurance,as required by Section
3900 of use LOW,Codc.far Ne perform um,0 the work for which this permit is issued.
My WorkeM1s Co penuuon 1 n¢cams and Policy number sre:
Cartier: Policy NO.: 0/11 SS O/6 7
CERTIFICATEPL
61 OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
musseclion need not W complexed if de permit is for one hundred dollars($100)
or less)
I emify that in the performance of to work for which Nis permit b ismcd.I shall not
employ any person in any manner an as to become Subject to the Warkets7Compenation
Laws of Califomia.Date
Applicant
NOTICE TO APPLICANT:If.after making Nix Certificate of Excmptian.You should
become subject to Ne Workers Compensation provision of the labor Cods.you must
.J O forthwith comply with such provisions or this Permit W deemed revoked.
Z � CONSTRUCTION LENDING AGENCY
PI hereby affirm Nat there is a construction lending agency for the performance of
C 7 the work for which this permit is issued(Sec.3097.Civ.C.)
B] 0Lenders Name
a Lender's Addhcxs
V 0 I cenify dam 1 have rod that application and sutc that the a W.e information Is
C F cording l agree to comply with all city and county oNinances and luxe bwt r arms t e
0 V abovingcanswaioo.and hereby ectionmmprexcnuti.es of dais city to enter upon dad S
r W ahovc(We)agree
to ortySaw,for minify an keepha.
(We)agree to cove,indemnify and keep harmless the City of Cupertino admit
F'raj? liamance,unnes of the
granting
r wing expense which may in any way accrue againt sett City
CJ z in
CANTe ONDE0.5TANOS ANDof WILLWILL COMPLY WITH ALL NON-POINT Issued by: Date ."L.Z�— Q��
SOURCE R TIONS, a ( tl j
V S Re-roofs
Signature ofKpi5licamuCoots
ct r Data
HAZAIED USM RIALS DISCLOSURE Type of Roof
Will dad applicant or t lure WiIA g occupuumre or handle hvallous material
drefined by the Cupertino Municipal Cade,Chapter 1.11*stall dad"cardsand Safety
c.Section 25532(a)± All roofs shall be inspected prior to any roofing material being installed.
0Ycs
Will the applicant or trim building Occupant use aquiparmt or deices which If a roof is installed without first obtaining an inspection,I agree to remove
emit W andous air contaminants az defined by dac Bay Area Air Quality Management all new materials for inspection.
Garic,?
Q yes �U
I have mad he haaardnus materials requihemenes under Chapter 095 or the,Califor.
nia Health&Safe)y Cooke,Section 25505.25533 and 25539.1 understand that if the Wilding
Jou not du nt chi am a¢rant Nat it b my responsibility M Willy the w:c'Upau of the
rcquimmcnu chmdia an priorwissuar¢cofaCcrufica¢of Signature of Applicant Date
d an All roof coverings to be Class"B"or better
Owner ora orlreJ agcm Dat