04010142 CITY OF CUPERTINO ` • '' '� " ^' �'c:"` " ='
BUILDING DIVISION PERMIT CONTRACTO,RINF„O.,RMATIQTu
N
BUILDING ADDRESS: PERMIT NO.
04010142
74 rT TPPC)RI) CT R'S NAME: PERMIT LSUE DATE
1ARCHITECTfENGINEER
E:
SANITALING RY OL NO.
: BUILDING PERMR INFO
BLDG ELECT PLUMB MECH
0 0 0 0
u00 LICENSED CONTRACTOR'S DECLARATION Job Description
U w I hereby affirm that 1 Am Hamed under provisions of Chapter 9(commencing
^�
with Section a.d0)of Divixmn3of chc Business and Pro@ssiam Code.and myliccnsc is
�„ imm� n.and rc"` ADD 968 SQ. FT. /REMODEL
n License Class Lk.tr
LFp Date CSDEC L^e.
e ARCHITECTS DECLARATION
Y¢� 1 understand my plans shall he used o Public rtcorN I,
''o Licensed Professional
0
3 OWNER-BUILDER DECLARATION �/)0
I hereby allirm that I am exempt from the Contractors License Law for the
DO following mamr.(Secuon 7031.5.Business and Predilections Cade:Anycity or county
R m�+ which requires a permit to..M.cl,aluen improve,demolish,or repair any structure
w�'^ prior an its issuance.also requires the applicant for such permit o file a signed statement
EiGthat he is licensed pursuant to the Provisions of due Contractor's Liccmo Law(Chapt'r9 Sq.Ft. Fl oor Area Va NI n' u�
rel-$ (mmmerming with Section 7")of Division 3 or the Business and Professions Code or
dal I�S,Jp7 ttr+{{!
_ Nat he is exemPt therefrom and the basis for Ne alleged exemption.Any violation of �a
Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of 3 g���I lgt�er0 0 Occupancy Type
not mor don Bm hundred dollars(5500).
❑1,ss owner of the propmy,ar my cmplayca with wage as the'v sol.compensation,
will do Ne work and the swctum is not intended m offered forade(Sec.7044,Business
and Pmfessiom Code:Tee Contractor's License Law dues not appy to an owner or - Required Inspections
property who budidsMireprom..theme ,and who doasuchworkhi aelforthough his
own employ.,provided that such improvements Are,not inrcMed oroffucd for We.IL
however,the building or improvement is sold within one yeti of completion,due owner.
build.,will have the burden of proving that he did not build or improve for purpose of
Ie.).
1.u.1 of the pro y,am exclusively contracting with licensed conuacmn to
tttonswct due project C.7 ,Business and Fred ns Code:)The Conouoors Li-
cense taw dors n apply inownerofpro ny ilds or improves thereon,and
who cc Us Auchp Acts with a con ref( is d pursuant to to Contractors
Lice aro
❑lame rept on m, 0&.P Cfor this human
ORKER'S COMPEN A N C ION
Ih elp.or&,putely of perjury of following declaraumu:
In.,and will mainuina CcruBcateof Conacn oself-insumfor Workets Compcm •
sation,As provided for by Section 37M of Ne Labor Code,for the Performance of the
work for which this permit is issued.
❑1 ham and will maintain Workers Compensation Irmance,As requited by Section
3700 of tho Labor Code,for the performance of the woh for which this permit is issued.
My Workers Compensation Insurance carrier and Policy number an:
Cvner. Policy No.:
CERTIFICATE OF EKEMPTION FROM WORKERS
COMPENSATION INSURANCE
(Thisseetion need not Meamplcted irthe Permit is form.hundred dollars(glfl0)
M lcai)
I corufy that in the performance of the work for which this Permit is issued,l shall not
employ any person in any manner an as m bemmc subject o the Workeri Compensation
Laws of Caliromia.Dam
Applicant
NCnCE TO APPLICANT:If,after making Nu Certificate of Exemption,you should
become subject to the Worker's Compensation provisions of the Labor Crude.you most
.,O foMwith comply with such provision or this Permit shall M doomed revoked.
Z CONSTRUCTION LENDING AGENCY
�-. 1 hereby affirm Nat then Is a construction lending agency for the perfurmam<of
a> the work for which this permit is issued(Sec.3197,Co.C.)
fA Q Lenders Name
=z Und,ea Address
U C) I comfy Nat I have nod this apptiadern and state that the above Information is
rS, correct.I agree to comply with all city and county ordinances and sun laws mlating to
�U building construction,and hereby Muchmore repromnutives of this city to enter upon the
W above-mentioned pmPerty for inspection purposes.
aill�c
1.save,indemnify and ace,harmless the City of Cupertino against
FN e mcustsandexpeTl may in any way accrue against said City
U z the Sooting of is pc it
NDERSTANDS AN L COMPLY WITH ALL NON-POINT Issued by: Date
ERELATIO ��L�)�
P Re-roofs
on, lic HAZARDOUS MATERI DISCLOSUR Dare Type of Roof
applicant or future building upantstore or handle havarduus material
dered by de pe
Cunino Municipal Codc.Chapter 9.11,and the Health and Safety
.Zcuun 3553](.)7 111111s����s� All roofs shall be inspected prior to any roofing material being installed.
YuNu
will the applicant or future building occupant use equipment or devices which If a roof is installed without first obtaining an inspection,I agree to remove
7�,uimmcria,
it havardous air contaminants As defined by the Bay Area Air Quality Managcmcnt all new materials for inspection. •
District?
D Yca No
Ihavemadtheh rows aterialsrequire rats un rCh Icr6.95ofthe Califor.
HealNkSafcty ,Sec.. 25505.25533.5 255 .Ian theifdue Wilding
s trot cmnntt ve a rte l that it u my ns it ouly um occupant of ohe
cchm.nbc nortoi ceor m eninamAaf cap ay ignature of Applicant Date
7) 22 2
oens r Ito
s horiv a m Date All roof coverings to be Class"B"or better
T Ito