05020066 CITY OF CUPERTINO �y°-v}�c{��.r�s.y.�:+��
BUILDING DIVISION PERMIT 'WONT, lt1�OR I�wIr OLllrlA�1�V,�1�
BUILDING ADDRESS: PERMIT`b5020066
ER'S NAME: PERMIT ISSUE DATE
C
E; SANITARY NO. CONTROL NO.
ARCHITECTIENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
LICENSED CONTRACTOR'S DECLARATION Job Description
u 1 lamby affirm Nal I are licensed under provisiau of Chapter 9(commencing P
wath Section
in full ranraof of Division 3 of Ne Busincm Brad ProreWnna GadC,and my licence 4
ee andd,Rat t
'= LiceoseClua Lica ADD 861 /REMODE ? O AMP PANEL/OFFICE
Dae Gmuanaf LAUNDRY/NOOK/MA �"I'IAB99
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ARCHTTECT'S DECLARATION
1 underwnd my plims.hall W used Is public mcards
5� Licensed ProfessionalOWNER- r(�
ION
1 Wmby AMM that I are exempt fmm irk CoER nt aloes Ucmm law for the
00 fallowing moan.(Section 71"1.5,Business and Professions Cade;Any city or County
$(L which requires a permit to construct,alter.improve,demolish.or mpoir any structure
k.ZC prior W its issuance.&Im saluims the applicant for such permit to Ole a sigaed statement
thatin,a licenmd pursuant to the provisions of the Contractor's Lkmnm law(Chapmr 9 Sq.Ft.Flooha VVILL)IIV �QPO 0 0
51 (commencing with SeNoa70X))of Divkion3 Crux,Buslneuand PmfeulonsCode)ur s3k
e3 than Is exempt dmrefrom tib de xeatio
basis for the alleged exemption.My violn of
Section 7031.5 by any applicant for a permit subjects the applicant to A Civil penalty of APN Number Occupancy Type
.m roam Nan live hundred dollars ISS00). 36937005 . 00
❑I,a ower of tha pmpony,m my employee wi0 w les u their mle eompewtion,
will do thework,and the structure is notfnended Gartered foraale(Sec.7014.Buuneu Required Inspections
and Profession Coda The Coruscate.License Law does ne nsl apply to an owner of (I Q
pmpeny w ho builds Or improves thereon,and who doeuuh work himulf Or through his
own employsm,provided that Inch Improvem,nu are not Intended oroffered forale.If.
however,On building or Improvement is mid within aro year ofcmnplema.the owner.
builder will have de burden of proving WI W did not Wild Or Improve fm purpose of
mk.).
1,as Owner of the property,am exclusively conuuling with licensed conlncuts to
=1 the project(Sec.7044,Business and Profusion Code:)The Canlrmmr's Li-
cense law does not apply to an owner of pmpeny wW Wilds or Improves themm.and,
who contracts for such projects with a conlruWr(O licensed pursuant to the Conummes
LIC..Law.
❑I am exempt under Sec. ,B h P C far than wan
r Data
YORKER'S C P•1 O DECLARATION '
I Mmby sham under peas of perjury an of the fallowing declarations:
1 haw and will malnal.•CeNfium of Consent to self-Insure far Waftes
Is provided for by Sutton 3700 of the Labor Code,for the performance of the
work for,which this permit is issued.
❑1 have and will maintain Worker's Compensation Insurance,as required by Section
3700 of the Labor Code.far the performance of the wart far which this permit if issued.
My Worker's Compensation Insurance carrier and Policy number am:
Cartier, Policy No.:
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(Thissectiun need not becomplemd If 1W Mrmit is foram hundred dollars($1010
or leu.)
I unify that in the perfarsn.m.of the work for which this permit is issued.I shall no,
,mpayany permn In my mmnrsrtp sub ttothe Workers'Compensation
Lawaof Celifamie.D.w 1t ss
Applicant
NOTICE TO APPLICANT:If,sfer nutkiffit this Certificate of Exemption,you should
become subject 0 the Workeh Compensation provisinm of the Labor Cade,you must
O O forthwith comply with such provisions or Nu permit W deemed revoked.
U; CONSTRUCTION LENDING AGENCY
E" I hereby affirm that them is a Conswction leading agency lar the periarmaue of
the work for which this permit isissued(Sec.3097,Civ.C.)
CL.
Q Lender's Name
w7.2 Lender'sAddw
V Q I cenify that 1 have mad this applkadw,and tae that the W.information is
U. COMM i agree to comply with all city and county oNimnca and sue laws relating to
O U Wilding construction,and hamby authorize representatives Or this city a ever upon the
W ,hove.mentioned PMPCRY for lnpecuon Purposes
LL (We)agree to ave.Indemnify and keep harmlrm the City of Cupertino against
ver,n IlWilites,judgments,costs and expenses which may In my way accrue agarol acid City
In consequcme of the gutting of this permit
APPLICANT UNDERSTANDS AND WILL C9klPLY WITH ALL NON-POINT Issued by: Date Q
SOURCE REGULATIONS. tD u, -
S - Re-roofs
Sign uum of ApplicamiConuamor Dere
HAZARDOUS MA ALS DISCLOSURE Type of Roof
Will the applicant w fuuuc Wilding a cupantswreorhandl.harudam nuatmal
m dented by the Cunfno Municipal Code.Chapter 9.11,am the Health and Safely
semanzssaz(.pe)7
C]Y. O` 'No All roofs shall be inspected prior to any roofing material being installed.
Will the applicant or future Wilding occupant use equipment or devices which If a roof is installed without first obtaining an inspection,I agree to remove
t havardou air commitments u dcfrosd by that Bay Area Air Quality Management all new materials for inspection.
aI ict7
p Yes No
I have mad Ne hmadrma MawriA Imquiroments under Chapter 6.95 of the Califor.
nu H.[O6 S.r tYC.de Sections 25505.35533uu125534.1 undenmrd thstifthe bWldial
does not currently have a unman that It is my responsibility to notify the oceupml of the
requlremcnts whiciZ�h most be t bawl. cc qfa CertiIII of occupancy. Signature of Applicant Date
o All roof coverings to be Class"B"or better
Owner or authorised agent oto
r