04080218CITY OF CUPERTINO
�
U
3
i
O
<that
0
$
,�
Q
.`�.
QLcndcr's
z
Q
Fcomem
U
y
N
z
'—'
BUILDING DIVISION PERMIT
�CONTRAG-TnR INFORMATION
OUILDING ADDRESS:
PERMIT NO.
04080218
542 CEPAR TREE 2 -T -
OWNER'S NAME:
PERMIT LSS[IE DATE
E:
SANITARY qftOL NO,
ARCHITECT/ENGINEE0.:
BUILDING PERMIT INFO
TBLDG, ,ELECT PLUMB MECH
LICENSED CONTRACTOR'S DECLARATION
�' ±1 J tiA�V.iui3 �,�
Job Deseripti
I Withy affirm Thar I am licensed under provisions Of Chapter 9 (commencing
n
with Section 7") of Division 3 of Ute Butimem and Professions Code. and my license is
License lass effact. Lic.p
TENANT IMPROVEMENT � Mr,
Dae Cmummun
INTERIOR REMODEL/SKYLIGHT
ARCHITECTS DECLARATION
I undersunu my Plans shall be uxJ u public records
cow,,
Lflll3ry~Wl(sf �
Licensed Prufcasiunal
R DECLARATION
Oat
I hereby .(Erre thatI am exempt Com oto License taw for the
11. exempt from the Co
o Cod.: Any city
maxo inter Code:
(Soden ]fn l.5. Business and firmon.
de stcourtly
demolish.
which requires alcor, impmw, demolish. fi repair any swnure
which re rinse a
pnoftotu issuance. alsore airs; ft mem
for such Comonsrmiuofile aicensc
tesfWvisiappon
Sq. Ft. Floor Area
Va tlI[�o�000
ensedpalrantto of aw(Chastat
(Commescing wdpursuam 70th)) of visions of theeBusinessnd Preclaw(Chapter9
nvilatdc)on of
that xempttSection,and of Oasis N Of the Business and Predications
Any
that be u exempt tMrefrom and the buss for the allegrA exemption. Any violation of
he is
APN Number
Occupancy Type
Section ]031.5 by arty applicant for a permit subjects the applicant to a civil penalty of
not mare than Eve hundred dollars (5500).
❑Luowoer Of ole popcny, ar my employees with wagesastheir sole eompeuaUon,
31634024.00
Inspections
win do mo work, and themocture is oat intended or anew for son IS". low. Business
and Professions Curb: The Contractor's License Law dors not apply to an owner of
Required
q p
property who WilN or improves thereon, and who dosoueh wink himself. though his
Own employers, provided tat improvements are not invtnded or anew for Mk. If,
however, Ne building or imp nwrom is sold within one yeti of completion, the mveal-
builder will have the burden of paving Nm he did rwt Wild or improve for purpose of
al ).
I, as Owner of the property, am exclusively contracting with licensed contractors to
ns mot the plainer (Sec. 70uM. Business and Professions Code:) The Contractor's LI -
came taw dos not apply to an owner of Oopeny who Wilds or improves thereon, and
who convects for such projects with a eontncteCs) licensed pursuant to the Compactors
License Law.
B & P C for this mason
❑tun exempt no ec.:/
may—
Own I - E Da¢ 2
WORKER' COMPENSATION DECLARgTIpN
I hereby affirm under Perot of perjury oro of the fblMwYing declarations:
have and will maintain a Certificate of Conscm to reli-insum for Worker's Compcn-
un, as provided for by Section 37W of the labor Code, for the pcdarromen of the
work for which Of, permit is issued.
❑ 1 have and will maintain Workers Compensation Insurance, M required by Section
3]W of the Labor Code, for the performance of the work for which this poorest is issued.
y Worker's Compensation Insurance cannot and Policy number am:
My,
Cartier. Polity No.:
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(ibis section need not W completed if tbe permit is foram hundred dollars (SI W)
nr loss.)
1 army Nm in The performance of me work for which Nis permit a issued. I shall not
employ any person in any manor so M or become subject to tW Workeri Compensation
Laws of California. Dam
Appliant
NOTICE TO APPLICANT: If, after making this Cenifcate of Exemption, you should
become subject a me Worker's Compensation provisions of Ne labor Cod., you must
forthwith comply with such pmvisions or this permit shall he deemed revoked.
CONSTRUCTION LENDING AGENCY
that Nem is a eonsto,. inn lending agency for the performance of
1 ho,
which Ou
th. work fur which Nis permit a iuod (Sec. J(9], Civ. C.)
AName
Lenderi Address
dd
1 certify that I haw mad this application and state that the above information u
I agree to comply with all city and county ordimmums; and some laws miffing to
building construction. and hereby authorre representatives of this city to enter upon thc
above-memiaod property for inspection pm m ses.
(We) agree to save, indemnify and kap harmless the City of Cupertino against
(„[
liabilities ,judgments. costs and expenses which may in any way acme against Mid City
U s�
in consequent. of the "Mung of his p))rtnit.
APPLICANT UND¢itSrAN AND WILL COMPLY WITH ALL NON -POINT
Issued by: Date
SO�U�RC/E g,WYIONS.
/s/y��
,f.11-
Re -roofs
Type of Roof
in�Applian on for f
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant of future building Occupant tore or handle hasnamour mau:nal
dcfinc0 by The Cupertino Municipal Code. Chapter 9.12. and Ue Health and Safety
Cox
DYra 35532(0)? XH
All roofs shall be inspected prior to any roofing material being installed.
If a roof is installed without first obtaining an inspection, I agree to remove
Will the applicant or future building occupant use equipment or devices which
I hazardous air contaminants as unlined by me Bay Area Air Quality Management
all new materials for inspection.
trio?
l.iHcCalc,
0 Yes YTiNu
I have reW the hxuaNnusmatertals requirements untkrChaper 6.95 of the Califns-
alth &SafelyCode. Seetions 25505.25533 and 25534.1 undersand thattfthe Wilding
s not currently haw a tenant that it is my respouibilily to foodytheocupant of the
uirements u� metpnoreiasamecaracenibatoOr cupwy
Signature of Applicant Date
All roof coverings to be Class "B" or better
wfer or>alnod.<e agent Da