04110145 CITY OF CUPERTINO
BUILDING DIVISION PERMIT aCONTRACTORINFORMATION s
BUILDING ADDRESS: PERMIT NO04110145 4110145
OWNER'S NAME: PERMIT ISSUE DATE
NE: SANITARY P. CONTROL NO.
A CHITECT/ENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
0 0 0 0
u00 LICENSED CONTRACTOR'S DECLARATION JobDescri tion
.
w I hereby affirm Net 1 am Heomed under provisions of Chapter 9(commencing IJ
Z� with Section 7")Of Division Sofmc Box incs..ad Proemium,Codc.md my license is
^�„ mmumreeand`ff"'' ADD 668 . 8 ' (MS SUITE) /556 ' GARAGE
ZZ License Class Lk.N r o Dotc Contractor
f'J' ARCHITECTS DECLARATION
1 underuand my plans shall W used as public resounds
;LLu
O Liccrscd Pmfcssional
` 3 OWNER-BUILDER DECLARATION
1 herebynaso ,affirm on 1 em exempt from dm Cmithis o e:Any c Law for the
O O which re mason.permit
t 703 L5,Business and improve.
demolish,
Code:Any city or county
$ which requires a Pemst re construct.the altep improve,h permit t or repair any swment
H Z i that W i rs issuance.pursuant 10 the thovisiappo s nt offor sucContra torus U l nsid Law x hapten t
that he es licensed tion 700)of Division
of the cBusi em License Laws Code)Y Sq.F[. Floor Area ' V.uahon
¢_O (commencing with Smtien TOW)of Division]of the Businry and Professiors Code)or
i 3$ Nat he is exempt therefrom and the hasu far the alleged exemption.Any violation of •-r:r rswmi.n..p
Section 7031.5 by sty applicant for a permit subjects the applicant a civil penalty of 3 4ffTV 4tr V0 0
not mole than five hundred dollar:(s5ro). Occupancy Type
I,ssowner of Ne proptny,mmy cmPloycu with wages as their sole eompensadon, f� tI n r�r�q
will On the work and the structure is not intended mattered foraale(Sei.1044,Busim.. Required
egaiieas InspeCUO- 't Y
and Pmkziors Cods:The Contracmrs License Law docs not apply to an owner of ` f �L
as 11 ,
progeny who buildsarimproves memon,and whodoes such wart himulfor through his
n employers,provided that such improvements are not intended oraRered for mle.if,
however me building or improvement is sold within one Year ofcompletion,the owner I-, ttt
builder will haw the burden of proving Nat he did not Wild or improve for purpose of
u]a.).
❑h as owner of the,propeny,am exclusively contracting with licensed contractors to
construct the project(Sec.1614,Business and Professions Codc:)The Contractors Li 1' t r,
cense Law dors not apply to an owner of property who Wilds or improw s mcreon,and
who contracts for such projects with a contracmr(s)licensed pursuant to the Contractors
License law.
of min aempt under Sec. ,BB PC for this on
Owner - 1 Data
W RKE1� MPENSATION DECLARATION
I bunchy alimt under penalty of perjury on of Or following declaauors:
,award
will maintain a Certificate of Comcnuo sclGinsure for Workees Cont
.as provided for by Section 3100 of the labor Code,for the performance of the
for which this permit is issued.
1 have and will maintain Worker's Compensation Insurance,as remained by Section
37W of the labor Code,for the performance of the work for which this Permit is issued.
My Workers COM penmLion Insurance carrier and Policy number arc:
Carrier: Policy No.:
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
anti section need not boeompleted if the permit is foram hundred dollars(5101)
or less.)
1 unify mat in the performance of the wart for which this Permit is issued,1 shall not
employ any person in any manner so u to become subject in the Workemi Commexatien
Laws of California.Data
Applicant
NOTICE TO APPLICANT:If,oiler making this Cmuricate of Exemption,you should
become subject to the Worker's Compensation provisions of the Labor Cedo,you must
-JO forthwith comply with such provisions or mis permit shall to deemed revoked.
z'" CONSMUC71ON LENDING AGENCY
f—' I hereby affirm Out there is a comoiction lending agency for Oc perfmm uce of
IY the work or which m¢permit is issued(Sec.3097,co,.C.)
fz7 0 Landcrs Name
=z Lenders Address
V 0 I certify Out I have read this application and stoma met the ebovc information relating to
0 budder I agree to comply with all city and county madoxyof and slate laws relating e J/
0U move-mendoncilpmand forebyauthonpurposexnativcsof miscity to enter upon me
CL above-mentioned property for inspection purposes
(Wc)agree to cost,andex,moand keep harablassim tWCity
ni Cupertino id City
EU'Z liabilities.judgments.graining espersrswitch may in any way tsetse against said City
V Z inconsequenceNDERf OC `rANDfmis permit.
^ AP ICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT Issued by: Date
S EREGUTA NS.
signaw plica tactor Re-roofs
ZARDOUS MATERIALS DISCLOSURE Type of Roof
ill me applicant or future building oxcirmuL store or handle hazardous material
az defined by the Cupertino Municipal Code,Chapter 9.12,and the Health and Safety
Code. DYsour255)2(x)? yTINo All roofs shall be inspected prior to any roofing material being installed.
Will the applicant or future Wilding eocupant are equipment or devices which If a roof.is installed without first obtaining an inspection,I agree to remove
't harmdnm air contaminants ss defined by de Bay Area Air Quality Management all new materials for inspection.
rict?
❑Yes 'fT No
1 have mad Or h.rihmas'mmerials requirmsems under CWpter6.95 of me Califor-
nia Health 6 Safcty Cock,Secliurs 25N)5.25533 and 25534.1 understand thaudthe building
dors not currently haw a tenant,mat it is my responsibility at notify the occupant of the
req ' whiehmuat Tat giortoissumaofaComficawofaap y Signa tureofApplicant Date
menel
_ l s
Owner uthmloedagent ,m All roof coverings to be Class"B"or better
f .
CITY OF CUPERTINO
BUILDING DIVISION PERMIT aCONTRACTORINFORMATION s
BUILDING ADDRESS: PERMIT NO04110145 4110145
OWNER'S NAME: PERMIT ISSUE DATE
NE: SANITARY P. CONTROL NO.
A CHITECT/ENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
0 0 0 0
u00 LICENSED CONTRACTOR'S DECLARATION JobDescri tion
.
w I hereby affirm Net 1 am Heomed under provisions of Chapter 9(commencing IJ
Z� with Section 7")Of Division Sofmc Box incs..ad Proemium,Codc.md my license is
^�„ mmumreeand`ff"'' ADD 668 . 8 ' (MS SUITE) /556 ' GARAGE
ZZ License Class Lk.N r o Dotc Contractor
f'J' ARCHITECTS DECLARATION
1 underuand my plans shall W used as public resounds
;LLu
O Liccrscd Pmfcssional
` 3 OWNER-BUILDER DECLARATION
1 herebynaso ,affirm on 1 em exempt from dm Cmithis o e:Any c Law for the
O O which re mason.permit
t 703 L5,Business and improve.
demolish,
Code:Any city or county
$ which requires a Pemst re construct.the altep improve,h permit t or repair any swment
H Z i that W i rs issuance.pursuant 10 the thovisiappo s nt offor sucContra torus U l nsid Law x hapten t
that he es licensed tion 700)of Division
of the cBusi em License Laws Code)Y Sq.F[. Floor Area ' V.uahon
¢_O (commencing with Smtien TOW)of Division]of the Businry and Professiors Code)or
i 3$ Nat he is exempt therefrom and the hasu far the alleged exemption.Any violation of •-r:r rswmi.n..p
Section 7031.5 by sty applicant for a permit subjects the applicant a civil penalty of 3 4ffTV 4tr V0 0
not mole than five hundred dollar:(s5ro). Occupancy Type
I,ssowner of Ne proptny,mmy cmPloycu with wages as their sole eompensadon, f� tI n r�r�q
will On the work and the structure is not intended mattered foraale(Sei.1044,Busim.. Required
egaiieas InspeCUO- 't Y
and Pmkziors Cods:The Contracmrs License Law docs not apply to an owner of ` f �L
as 11 ,
progeny who buildsarimproves memon,and whodoes such wart himulfor through his
n employers,provided that such improvements are not intended oraRered for mle.if,
however me building or improvement is sold within one Year ofcompletion,the owner I-, ttt
builder will haw the burden of proving Nat he did not Wild or improve for purpose of
u]a.).
❑h as owner of the,propeny,am exclusively contracting with licensed contractors to
construct the project(Sec.1614,Business and Professions Codc:)The Contractors Li 1' t r,
cense Law dors not apply to an owner of property who Wilds or improw s mcreon,and
who contracts for such projects with a contracmr(s)licensed pursuant to the Contractors
License law.
of min aempt under Sec. ,BB PC for this on
Owner - 1 Data
W RKE1� MPENSATION DECLARATION
I bunchy alimt under penalty of perjury on of Or following declaauors:
,award
will maintain a Certificate of Comcnuo sclGinsure for Workees Cont
.as provided for by Section 3100 of the labor Code,for the performance of the
for which this permit is issued.
1 have and will maintain Worker's Compensation Insurance,as remained by Section
37W of the labor Code,for the performance of the work for which this Permit is issued.
My Workers COM penmLion Insurance carrier and Policy number arc:
Carrier: Policy No.:
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
anti section need not boeompleted if the permit is foram hundred dollars(5101)
or less.)
1 unify mat in the performance of the wart for which this Permit is issued,1 shall not
employ any person in any manner so u to become subject in the Workemi Commexatien
Laws of California.Data
Applicant
NOTICE TO APPLICANT:If,oiler making this Cmuricate of Exemption,you should
become subject to the Worker's Compensation provisions of the Labor Cedo,you must
-JO forthwith comply with such provisions or mis permit shall to deemed revoked.
z'" CONSMUC71ON LENDING AGENCY
f—' I hereby affirm Out there is a comoiction lending agency for Oc perfmm uce of
IY the work or which m¢permit is issued(Sec.3097,co,.C.)
fz7 0 Landcrs Name
=z Lenders Address
V 0 I certify Out I have read this application and stoma met the ebovc information relating to
0 budder I agree to comply with all city and county madoxyof and slate laws relating e J/
0U move-mendoncilpmand forebyauthonpurposexnativcsof miscity to enter upon me
CL above-mentioned property for inspection purposes
(Wc)agree to cost,andex,moand keep harablassim tWCity
ni Cupertino id City
EU'Z liabilities.judgments.graining espersrswitch may in any way tsetse against said City
V Z inconsequenceNDERf OC `rANDfmis permit.
^ AP ICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT Issued by: Date
S EREGUTA NS.
signaw plica tactor Re-roofs
ZARDOUS MATERIALS DISCLOSURE Type of Roof
ill me applicant or future building oxcirmuL store or handle hazardous material
az defined by the Cupertino Municipal Code,Chapter 9.12,and the Health and Safety
Code. DYsour255)2(x)? yTINo All roofs shall be inspected prior to any roofing material being installed.
Will the applicant or future Wilding eocupant are equipment or devices which If a roof.is installed without first obtaining an inspection,I agree to remove
't harmdnm air contaminants ss defined by de Bay Area Air Quality Management all new materials for inspection.
rict?
❑Yes 'fT No
1 have mad Or h.rihmas'mmerials requirmsems under CWpter6.95 of me Califor-
nia Health 6 Safcty Cock,Secliurs 25N)5.25533 and 25534.1 understand thaudthe building
dors not currently haw a tenant,mat it is my responsibility at notify the occupant of the
req ' whiehmuat Tat giortoissumaofaComficawofaap y Signa tureofApplicant Date
menel
_ l s
Owner uthmloedagent ,m All roof coverings to be Class"B"or better
f .