04110050 CITY OF CUPERTINO k^ re 7 :, 4ur .r"al4$a yis ,vi;6
Bmt.lnrvc OrvIs1oN PERMIT CONT, RX TiQR NF.0RMATION� --- - - - -— ::
BUILDING ADDRESS: PERMIT NO.
GK CONSTRUCTION & DEVELOPMENT 04110050
ZAM4AME,.'A�51'iNEPERMIT ISSUE DATE
SANITARY OL N0. -
ARCHITEcTaENGiNEER: BUILDING PERMIT INFO
BLDG ELECTPLUMB MECH
aJrOo LICENSED CONTRACTOR'S DECLARATION Ib Description
C I hereby affirm that 1 am ficuts d under provisions of Chapter 9(comOCSCO
mencing p
b with Seen..7")of Division Sof the Business end Pmfmciuns Codc.and my license is
o, in full fame and effect.
5EJ� ueenxeclu �a REVISION--REPLACE WINDOWS _
"FF°y DOW—ARCH DECLARATION NO NEW PERMIT ISSUED/ORIG. #04050154
C I understand my plans shall W feuTSd ss public meards - - -
JDU
;Q� Liccnud Professional
g OWNER-BUILDERDECLARATION -
i8 1 bcmby affirm that 1 am exempt[rum Inc Conuanors License law for the
o O following recon.(Soctlon 7031.5.Business and Professions Coale:Any city or county
K S9 which requi=a permit m emmilincl,alar,improve,demolish,nr.,.it any structure
m—r^ prior to its issuance.also requires the applicant for such permit to file a signed statement
dust W is licensed pursaanuo the pmviaionsnf the Conuacmh Licca¢Law(Chapter 9 Sq. Ft. Floor Area Valuation
yS
h� (<ommcncin8 with Selion TOf10)of Division of lM1C Btuilmcs and professions Code) $Q-
i $ Net he is exempt Ihemlrom and the buts for the alleged exemption.Any violation of
Section 703 l.5 by my ppncam far apetmh.ubjc.0 We Applicant I.a end penally of APN Number Occupancy Type .
not mom than five hundred dollars(ssoo). .
❑1.u owner of Ne pmpeny,or my employ=with wages w Jeb sole mmMnmdon, 326,1J029 00
will entire woe,and the swctureisnminunded or offered forsalc(See IDU,Basinru -
And Plofessums Cade:The Cnouacora Licere,I.A.d=our apply W an owner or Required Inspections ^
propcnywho builds or improves thereon,andwho doessuch workhimulf or through his _
own employees,provided that such improvements arc not intended oroRated for We.If.
however,the building or improwmenl is sold within one year of complation,Ne owner-
builder will hast the burden of proving that be did not Wild or improve fm purpose of
sale.).
L ss owner of Ice properly,.Business and confessional with:)ra,,C commoors to �\
coast,La Ice project(Sec.Toga,wneofand property
wh ions Cade:)The Conuacon, -
` cane law d=no, to an owner of properly who Wilds or impmvu Woman,And, -
who
enseLacufor such projeeuwith aconlr,emrp7licenud pursuant to We Conwnala - \
License Law. J`
m l,m/ezempt under See .B ir P C for this uuan v
p�.,rd - Date !•p
�. O' ���'''''''''Zk4l WORKER' ATION C
I hereby aRrm under penally of perjury one of the following declandans: -
have and will maintain a Cenificau of Carton,to uhf-insme for Worker's Compen- .. -
non,as Provided for by Section non of the Labor Code.for rhe perfurm,ne of the
work for which this permit is issued.
❑1 have and will maintain Worker's Compensation Insuransc,as required by Section37M of Labor Code.for be pcRarramoc of We work for which this permit is issued.
My Worker's Compensama Insurance cannot and Policy number am:
Cartier: Policy No.:
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(This section need nal be cmaphred if the Ismailia for one hundred dollarx($100)
or less.)
1 comfy Wal in the of....of de work for which Nis permit u issued.)shall not
employ any Person in any manner sn As to become subjen to the Workeri Compensation ..
Laws of California.Date
Applicant
NOTICE TO APPLICANT:If.after making Nis Cardrica,of Excmplion,you should
become subject to the Worker's Compensation previsions of the Labor Code,you must
.J O forthwith comply with such provisions at his permit shall be deemed mvokcd.
Z y CONSTRUCTION LENDING AGENCY
'C-, I hetehy affirm that Were is a construction lending agency for We performance of
QY tie work fur which Wu permit is issued(Sec.3W7,Civ.C.)
C ^n- Lenders Name
=z Lender's Address
V p 1 sonify that 1 haw read this application and Sum that the about information is
E•'
correct.1 agree to comply with all city and county ordinances and su c laws mlating to
C building conswction.and hereby authonae mpteunutivrs of this city to tour upon We
Y' above-mentioned property for inspection purposes.
liabilities.judgments,
ogre to taw,indemnify and tech harmless the City of Cupenino against
y in consequence
eosuang ezpcn=mit, may in any way acerucaPinstsaid City
U APPLICAeNTeUNDERSTANDSof this AND TWILL COMPLY WITH ALL NON-POINT Issued by: Date /
SOURCE REGULATION
- I l• Re-roofs
gneturc of ApplicaHAZZ DOUSMATERIALSDI URE Data Type of Roof
Will theapplicantor future buildingoccupant nomor handle HeaAousaarerial
as defined by the Cupertino Municipal Code-,Chapter 9.12,and the Health and Safety
Code,Schon 35532(a)? All roofs shall be inspected prior to any roofing material being installed.
❑YesCO..
Will the applicant or future building occupant tau equipment or devices which
If a roof is installed without first Obtaining an inspection,I agree to remove
I haardous air to
As recd by the Bay Area Air Quality Management all new materials for inspection.
W I?
❑Yea
Ihawsad Weharardousmaedalsmquimn ntsunderChapmr&95oftheCalifor-
nuFbalN&Safety CaM.Sectiau25505,25533 aa125534.1 unikrstaM Juslifthc Wilding
docs not currently haw a en=L W,I iI b my aaponsibihity m nodly IM acupanl of the
rcquimmcnuwhichmust elp'ar a re of Occupancy. Signature of Applicant Date
k¢ reae it.C9•oe
wncr or authorized age Dare All roof coverings to be Class"B"or better