02110071 CITY OF CUPERTINO
BUILDING DIVISION PERMIT CON.�TRA TORSINFORMATION:6
BD . RcWRNE AV JND ELECTRANICS & ELECTRIC BM1T1®2110071
GW47dfI'3K%KER RICHARD E AND NORTHR P5540 PURDUE PL APPLICAT1Dt'n2`YP2002
iONE: (408) 723-7886 SANITARY NO. CONTROL NO.
ARCHITEC(ENGINEER: BUIL IN ITINFO
BLDG E PLUMB MECH
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LICENSED CONTRACTOR'S
nvaimeDECLARATION
fChap
1 Mrehy affirm that l am licenu0 under dPiofiess o(s Conk. 9(commencing rr 5v E V IOn
�zro with Section dtfilfDivision 3af de Business and PrnfessionsCode.and mYlicenu is g5 O=af
<1L in full force and cffat `\\ Cc, qg\ I
o Z a Z Daii Class Con {
rp Dalc TSDE or .
K—qq1]W As small
ARCHITECTS DECLARATION !
a 1 understand my plans droll M used as public records
usf 3
U. Licensed Pm(cssinnal
OW NERBUILDER DECLARATION -J
ti I hereby affirm that I am exempt from the Contractors License Law fnr the $1000
�r-00 following mean,(Section 7071.5,Business and Professions Cone:Any city or county
K$� which requires a permit to construct,alter,improve,demolish,or mpair any structure
Fz�^ poor to its issuance,also myuires[be applicant l'or such permit no file a signed statement
< that he is licensed puccuam 1.do,provisions of to Cummcwri License Low p2bapmr9 3s(}Fa DD&Pfa Valuation
(commencing with section 7100)of Division 3 oflM Business and Professions Cole)or
Us Nal bes exempt thertfrom and the bests for the alleged exemption.Any violation of
Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of Pp Occupancy Type
nor m..fighfive hundred dollara(g5m). 501 - FINAL ELECTR CAL ENERGY
❑ Les owner of Ne properly,or my employes with wages uNeir sok compensation,
will da the work,and Restructure is not intended oroffcmd foraala(Sec.Trust,Business
and Professions Cod,:TM Congruence.License Law does not apply m an owner of egmre nspec[ions
property who builds or improves thereon,and whodoessuch work himulfor through his
Own employees,pmvided that such improvements eta not intended oro@rcd for sale.If,
however,the building or improvement is sold within one year of eemplafion,the owner-
builder will have the burden of pmving that he did not build or improve for purpose of
sale.).
❑I,as owner of Ne property,am exclusively contracting with licensed contractors to
construct the project(Sec.7044,Business and Professions Code:)The Conuacme.Li- _
cense law does am apply to an owner of property who builds or impmvm Merton,and
who contracts for such projects with a nmtracmrbo licensed pursuant to the Conuacmr's
License law.
❑1 em exempt under Sec. B&P C(or this moon
Owner Dam
7031" WORKER'S COMPENSATION DECLARATION
I hcsoby aifmm under penalty of perjury one of tho following declautimme
I have and will maintain a Certificate of Cavum to self inmre for Worker's Compnsm
'00
ion,u provided for by Section 5710 of the Labor Code.for the performance of Je
rk for which Nis permit is issued.
rl I have Brad will maintain Workers Compensation Insurance,tl required by Section
of Ne Labor Codc,fnr the performance of Oe work for whichNis permit is issued.
y Worker's Compensation Insurance cuocr and Poliy number are:
rtier. Policy No.:
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
Constriction nerd nm hecomplcicd if t e Permit is forone hundred dollses(SIM)
less.)
I certify that in performance of the work for which this permit is issued.l shall not
employe rano inpny ma come mMwmc suhjemmthe Workeri Compensation
La PC a. al
plicate ILfA.N
N ICE TO AP :If,a ser making this Cenifcale of Exemption,you should
become subject to the Worker's Compensation provisions of the Labor Code,you must
D Z foMwiN comply with such provisions or this permit shall M deemed revoked.
z O CONSTRUCTION LENDING AGENCY
[—i I hereby Upon Nat there is a construction lending agency for the performance or
Ix the work for which his permit is issued(Sec.3007,Civ.C.)
aQ lender's Name
z Lcndcr's Address
U 0 1 certify that I have read this application and state that the above information is
44 P correct,l agree to comply with all city and county ordinances and slam laws relating to
DU building construction.and hereby authorize representatives of Nis city to enter upon the
Lk7 above-mentioned progeny for inspection purposes.
(We)agree to new,indemnify and keep harmless the City of Cupertino against
ferry
liabilities judgments,costs and expenses which may in any way same against gid City
;�NT�
ce of the granting of this Permit.
UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT Issued by: Da
NS. Re-roofs
onuacmr Dam
HAZARDOUS MATERIALS DISCLOSURE. Type of Roof
Will dm applicant or furore building necupam Goreor handl,treat t..material
defined by the Cupertino Mu "Par CMC,Chapter 9,12,and the Health and Safety
ode,Section 25532(a)1 All roofs shall be ins ected rlor to an roofin material bein Installed.
❑Yea NoP P Y g gWill the applicant lir future Wilding Occupant use equipment or dc.iaes whish If a roof is installed without first obtaining an inspection,I agree to remove
mit ho.oh ni air contaminants Orford by the Bay Area Air Quality Management all new materials for inspection.
District's
❑Yes i Nu
1 have read the havardousmakrials requirements under Chapter 6.95of Ne Califor-
nis Health&Safcsy Cole,Sectitms255 M255J3 d255M,I understandthaiftM Molding
Nes rrently ba a comm,Nat it is my mrgmvibility m notify rM occupant of too=-z=ugyhich nM tryimmissuanceof.CenilieamofOccupency. Signature of Applicant Date
neemauthatived agent Data All roof coverings to be Class "B"or better