05050085 ;IWNER'S
TY OF CUPERTINO "' a"�4 `1 i"' ** '' 11 '''A'
BUILDING DIVISION PERMIT �kCONTRACTOR INFORMATION
ING ADDRESS: PERMrfN0.
DWK CONSTRUCTION 05050085
NAME: PERMIT ISSUE DATE
E:
SANITARY OL NO.
ARCHITEC(ENGINEER: BUILDING PERMITINFO
BLDG ELECT PLUMB MECH
0 0 0 0
.00 LICENSED CONTRACTOR'S DECLARATION Job Description
ib C m Nu iO S1 hereby affirm l am licensed under previsimof Chapter 9(commencing P
b So aeetion]IXM)of Division Sof We a.m.and Pref firms Codc.and my lice..is
in full forte and cffCCL
Lan.Class- REVISION--TRUSS CAL.
� TSDECLARATION
ARCHITECS DECLARATION
Dam Contractor
NO NEW PERMIT ISSUED/ORIG. #04110067
1 undcnund my plans shall W used as public meet&
31U
G Licensed Professional
OWNER-BUILDER DECLARATION
.�i 1 be¢hy from Out l em evempt form Ne Contractors License Law for the
00 following Semon.(Section 7031.5,Business and Professions Code:Any city or county
5$ which mquires a Permit to ennstorcL alar,improve,demolish.or repair any swetum
Z} pnar Wsi censod C,aI3U fCQUI(CS IIIC dppliCLll forLICK(ICllllllto RlC esti gale(Sldmmcnl
F tMtbcisliccnseJpursuantsotheprevisionsoftheConuacmhLianulaw(Chepmr9 Sq.F[. Floor Area Valuati�t1115
x�$
that
he Is ixemit thodomn]WO)of basisofrnfthe Busnexempt Professions Chic)or '?
that he u exempt fec¢from and the basis for IW ai1cgM exemption.Any violation of
Section 7031.5 by any appliamfor a Permit subjects the applicant to a civil penalty of APN Number Occupancy Type
not more than los:hundred dollars($s08).
❑I,as owner of the propcny,or my employeed with wages u Their Oce compensation, 37518004 . 00
will do the work,and the snuctum u not intended or offered fertile(Sec.7044,Business
and Professions Code:The Conmacmrs License Law docs ml apply m an owner of Required Inspections
property who builds or impmvcs i1ercan,and who does such work himself or through his
Own employes,provided that such improvements art not intended orORercd for Site.IL
bo mmir.the building or impmvcment is sold within one yens of completion,the Owner
builder will hoe the burden of proving that he did not Wild or umprow for purpose of
tile.).
❑I,as Owner of the propeny,am exclusively contracting wife licensed conmaou to (\
constructathe project(Sec.]014,weer ou and ny who Wilds
Code:)Tbom othormrs Lin
come law dors not apply to m owner of pfewou who Wilds m imprnvth Norton,and (1
whence Laeu for such projects with a conuacmr()licensed pursuant to the Convenors v
Owner law. \
❑I am exempt under Sec. .B h P C for this rem rn _\
Owner Dau
V
WORKER'S COMPENSATION DECLARATION
I botchy afrism under pemlty of perjury one of the fallowing emidaraliona -
7C33737.W
have and will maintain a Ccnufieate Of Consent m self-insum for Workers Compcm
n,u provided for by Section 3700 of the labor Code,for She performance of the
for which this pareh is issued.
have and will maintain Worker's Compensation Insu ince,u required by Section
of the labor Code,for the performance of the work for which this permit is issued.
Workers Competuation Insurance anise and Policy number artier, Policy No.:
CERTIFICATE OF E)rEMPr1ON FROM WORKERS'
COMPENSATION INSURANCE
(Thissection need not be comphood if the fefmil u fomne M1undrM dollars(51007
or It..)
1 anify that in the s rfmmance of to work for which this permit is issued.I shall not
crept,any'person in any manner.as In become subject,.de,Workers Compentation
Laws of California.Date
Applicant
NOTICE TO APPLICANT.IL after making this Certificate of Exemption,you should
become subject in the Worker's Compensation provisions of IW Taber CMC,you mum
Z rudwith comply with Such provisions or thio pcmtit Shall the deemed mokcd.
'Z O CONSTRUCTION LENDING AGENCY
[—i I NoSby aR,m Out f.i..construction len lft.,cmy for tine pe,formana of
a the work for which Nis permit is issued(Sec.3047.Co,C.)
W�Q Undoes Namc
7 Z Lender's Address
U 0 1 comfy Nat I have read Ws appliatim and sum that tW aho a information is
cmtmu I agree in comply with all city and county oNinances and sum laws relating to
�YJ building construction,and hereby authorim represematimS of this city to enter upon Ne
r W above-mentioned pmKrty for icepcction purposes.
,r y (We)agree to save,iMGmnify and keep harmless Ne City of Cupertino against
rp Oabilides.judgments,costs and expenses which may in any way accrue against said City
U in consequence of the granting of this Permit.
^ APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT Issued by: Date
SOURCE REGULATIONS.
Re-roofs
Signature of ApplicaADem
HAZRDO
HAZARDOUS MATERIALS DISCLOSURE Type of Roof
Will the a Cotton,or!Muni building e.apmt mote or handle Health and
u defined by the Cupertino Municipal Code.chapter 9.12,and the Health and Safay
C
ode O e.zss3z(e)'r All roofs shall be inspected prior to an roofing material bei.
❑roe ❑N. P P Y g g installed.
Will thea applicant or room building mc. am use equipment or devices whim If a roof is installed without first obtaining an inspection,I agree to remove
rap g p yuipr Qu
hazardous air contaminants as defined by the Bay Arca Air Quality Management all new materials for inspection.
QYa 0N
I have mad the hanodous materials requirements under Chapser6.95 of the Califon
Health S SafetyCOM.Seedm 25515.M533 and 25534.1 understood thin ifthc Wilding
not currently hast a moan,Nat i,u my responsibility u of ify tW Occupant of theirements whim must W met peon toiMUMCC Ora Cemfieme Of acuPanl:y. Signature of Applicant Date
Owner or authorized agent Dam
All roof coverings to be Class"B" or better