04020159 CITY OF CUPERTINO "�
T �. '
BUILDING DIVISION PERMICONTRACTOR�INFOMATtfiT„QN ,
BUILDING ADDRESS: LEE COMELL PERMIT"04020159
OWNER'S NAME: PERMR ISSUE DATE
!E: SANITARY t4b. CONTROL NO.
ARCHITECT/ENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
u00 LICENSED CONTRACTOR'S DECLARATION
0 0 0
Iion7 affirmmal1amfthe Bu underprovisionsof Chapter vmy license
Job DCSCrIg l �� D
with Borman ndrfecDivisionJof tilt Business and Profcuinnx Codc.and mylimnx is 11(u1�L��I1lII
in full frame and error.
zpj zz_ Limens Class tie.» ADD 603 SQ. FT. d _
I- DOLL' Contractor
££ ARCHITECT'S DECLARATION
d I understand my pans shall he used as public records W cal �O
' -u +�
ii Licensed Professional
5 0.11 u-BUILDEfr DECLARATION q B is
Y I bmhy xrrnm Nal I R-exempt form the DECLARATION
License Law for the II'fv/IIII II'IL�
p O fallowing meson.(Section 71D L5,Business and Prefusum Cade:Any city or manly
$V which¢quires a Permit m cnnama,alar.impmsc,demolish,or repair any someone _
Fz< prior to its issuance,else mquims the applicant for such Permit to rile a signed saament
x thatheislicensed pursuantmthe previsionsofdoCommuter's UmnscLaw(Chaptcr9 Sq.Ft, Floor Area Valu tion
z�p (commencing with Section 7")of Division 3 of NC Business and Professions Code)or
a $ that he is exempt thmefmm and the bus for the allegrq exemption.Any violation of .ArDi.i,�y,,.,�
Section 703LS by soy applicant fears perms abjms the applicant m a civil pc.It,of 3 C4J i O W5I5'eir0 O Occupancy
not mom man Five hundred dollars,(M). P Y Type
I,u owner e(Ne progeny,m my cmploycu wim vnga u Meir salt compensation,
will do the wart[.and the sWemR Is sol intended or offered for sale(See.]ad,Business
and Profi.iana Code:The Ciubactm-a Limme Law docs not apply to an owner of Required Inspections
Property who builds or improv thermal,and who does such wart himself or through his
ownemployees,pmkcd mat such impromments art notimmild moBered for ale If,
however.the building or improvement is mid within one year of completion.the owncr-
builder will have the burden of proving that he did ret Wild or improve for purpose of
ala.).
❑1,as owner of the property,am exclusively contracting with licensed convectors to
construct the pmjm(Sec.lOaa.Bulinus ad Rafecsiona Code:)The Conbumri U
cctsse Law dors net apply in an owner of progeny who builds or improv Merton,and
who contracts for such projeeca with a eonsracmKU licensed pursuant to the Contractors
License Law.
❑lame ,B&PCf du an
Da eZ
WORKER'S COMPENSATION DECLARATTO
1 hereby Mr.under penalty of perjury one LI-VIwing declarations:
lase and will maintain aCcrtircate of Consent to self-hour,far WoNci 3Compen-
atian.to pmvidd for by Section 37M of the labor Code,for the performance of the
work for which Na permit is issad.
1 have and will maintain Worker's Compensation Insurance,as;requimd by Section
37M of the Labor Code,for the pedornamee of the work for which this permit is issued.
My Workers Compensation Inxnnce camimr and Policy number are:
Caller. policy No.:
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(SEs semi.need sol hp completed if IM permit is for enc hundred dollars(SIQ))
or less)
I¢nary that in the performance of the wart for which Nis Permit is issued.I shall not
employ any Pe rsb 'n n manne1a til !aVWmkcrsfCmaKnmmm
.or
NOTI aril
NOTI LICA .atom making this provisions
cane of Exemption,you ushould
most
become i to the Worker's Compcwtion provisiom of the lalnr Code you most
.,2 faMw mply wM such pmvislnm or this Permit shell M deemed revoked.
ZO CONSTRUCTION LENDING AGENCY
r- I hereby affirm that there is a construction lending agency l or the Performance of
W> the work for which this permit is issued(Sec.3097,Civ.C.)
{r] Leader's Name
z Lenders Address
IJ C) T cenify than T have mad this application and sum that Ne above information is
LL ^ correct.1 agree to comply with all city and county ordinances and sate laws rafting to
O trJ' building convection,and hereby aubmim mpetenativu of this city to enter upon thc
above-mentiond pmperty for inspection purposes.
Ly (We)agree in use,indemnify and keep harmless the City of Cupertino againat
y liabilities.judgments.costs and expemu which may in any way accrue against aid City
U z in consequence of the grammg of this Permit.
�+ APPLICANT UNDERSTANDS A ILL COMPLY WITH ALL NON-POINT Issued by: Date
S G ON
Re-roofs
art fApplican onbactm ax
HAZARDOUS MATERIALS DISCLOSURE Type of Roof
Will the applicant or future building mupam store or handle tis amoae material
at defined by the Cupertino Municipal Co Chapter 9.13,and the Health and Safety
Cdp Yeae.Smedon3ss33(e)e All roofs shall be inspected prior to any roofing material being installed.
Will the ,he.,or future buiIdi g occupant ax equipment or dmvicu which If a roof is installed without first obtaining an inspection,I agree to remove
ha.dous air colunolimms as tic cd by the Bay Area Air Quality Management all new materials for inspection.
❑Yes u
Ifatssad Nehaaardnua 25M5, requirerdMunder Chapter 6.93 of the ildia,
nines naW&Safcyy Code,Scdamhat it i3 My MS 429531.1 to tlN ec time building
Joys not currently hatce¢nank Nein is my res ilitymnntil'y p: ant of Nc
m atpsar Nreaw.f0c cy. Signature of Applicant Date
x agent are All roof coverings to be Class "B"or better