04090054 CITY OF CUPERTINO
BUILDING DIVISION PERMIT CONTRACTOR INFORMATION,
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BUILDING ADDRESS: PERMIT NO.04090054 4090054
OWNER'S NAME: PERMIT ISSUE DATE
E: SANITARY O OL NO.
ARCHITECTIENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
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appLICENSED CONTRACTOR'S DECLARATION Job Descri urea
U F I Mmby affirm that I am licensed under provisions of Chapter 9(commencing p
��i with Section 7")of Division3 ofthc Business and Professions Code.artd my license is
_ tprentan�e�ndeffeot. u if ADD 503 SQ. FT. (FAMILY/DEN ROOM)
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ARCHITECT'S DECLARATION
S a I undersand my plans shall M used ns public mmrds
In U
Soy LiccnscO Pmfcssional
OWNER-BUILDER DECLARATION
1 hereby affirm that 1 am exempt from IM Convacmts License Law far the
'0 following moon.(Section
?031.5,Business and Prorenaom Code:Any city or county
which requires a permit to construct.alter,improve,demolish,or terror any alrbelme
prior o its issuance.also requires the applicant for such permit to file a signed statement
xx< that M is licensed pursuant o the provisions of lM Contractor's Leaman Law(Chapter 9 Sq. Ft.Floor Area Q / Va shoo
yF� lebomeneing with Section 7")Of Division J of the Businen and Pro(essions Code)of
y that he It exempt mcmfrom and the basis for the alleged exemption.Any violation of r/
Secdon 9031.5 by any appiicantfor a permit subjects the applicant to a civil penalty of 3 MNgjyJg*100 Occupancy Type
not mom than five hundred dollars(S500). ^
T,as owner of the podiatry,or my employees with wages as their sale compensation,
will do the work.and the swcmre is not intended Or offered for sale(Sec.7044.Butts
and poressians Coat:The Conuxcota Llcntse Law does not apply to an owner of Required Inspections
property who builds orimprova menton,and whodoessum work himselforthrough his
own employees,provided that such improvements art notimended prone ed for sale.If.
however,the building or improvement is sold within one year of completion.Ne Owner-
builder will have the burden of Noting that he did not Wild or improve for purpose of
sale I
;�k
wner of the property am exclusively contracting with limped inumbnors to
Ne project(Sec.9064,Business and Professions Code:)The Convecols Li-
docs not apply to an owner ofproperty who Wilds or improves thembn,andcu for such projects with a comractor(s)licensed pursuant o fill,Cbnuacots
aw.
xempt uder Sec. B&P C for Nis Date OL ORKER'S COMPENSATION DECLARAi Ie yalfrm under Penalty of perjury ane bribe following declamimu:
and will maintain a Cenifica,ofConsent m self-insure fm Worker's Compen-
provided for by Section 3?M of the IaMr Code.for the per ibirra¢Or thewok orwhich this permit is issued. -
❑1 have and will maintain Workers Compensation Imunnce,is required by Section
37W of thc Labor Code,for the pcR nbou ce of the wok for which this permit is issued. '
My Wmian',Cbmp rbsmom Insunna canner and Policy number are:
Carrier: Policy No.:
CERTIFICATE OF EXEMPMON FROM WORKERS
COMPENSATION INSURANCE
(This section need hot becbopleed if the permit is poison hundred dollars($100)
or kis)
1 certify Not in the perfnrmancc of the work for which this permit is issued.I shall not
employ any person in any manner so as to become subjecua the Workers''Compmuation
Laws of Cahfom it.Date
Applicrm
NOTICE TO APPLICANT:If,after making this Certificate of Exemption,you should
become xubject to the Worker's Cion,madmi provisions of the Later Code.you mut
.J QM
fuwi0i comrevok
ply with such provisions or this permit shall k deemed ed.
Z2 CONSTRUCTION LENDING AGENCY
(-.' I hereby affirm drat Nem iea const 6nn leading agency In,the pcsfurmanm of
C 9 the wok for which this permit is issued(Sec.3W7.Civ.C.)
W A Lendets Name
=z lenders Address
U C) I certify that I have mad this application and suite that the above information is
correct.I agree to comply with all city and county on inances and stale laws relating to
0 t.) building construction.and hereby auhorn,representatives of this city to enter upon the
,r W above-mentioned pmpeny,for inspection purposes.
(We)agree to save,indemnify and keep harmless the City of Cupertino against
Iiabiliaes.judgmcats.caatssnd esp.which may in any way accrue against mid City
C.7 Z in cone^ APPLICCANTeUN UNDERSTANDS Aof thc gradifing orIND WILL COMPLY WITH ALL NON-POINT Issued by: Date
SOURCE REGULATIO 5.
( 1%xl.I!'n a%_ g�yc?y Re-roofs
SS urebf Applicam/Confiracor �� Date
l I HAZARDOUS MATERIALS DISCLOSURE Type of Roof
11 to applicant or future building Occupant store or handle hvndo ai
as defined by IM Cupertino Municipal Code.Chapter 9.12.and the Health and Safety
Code,Section 25532(a)? All roofs shall be inspected prior to any roofing material being installed.
LY �No
Will the applicant or future building occupant use cquipmenl or devices which If a roof is installed without firs[obtaining an inspection,I agree to remove
hazardous air contaminants as defined by the Bay Area Air Quality Management all new materials for inspection.
n?
❑Yes �N•'
I have mad the hararthms materials requirements under Chapter 6.95 of the Califm-
0"calth&SafcsyCodc,Sections 255(15.255]]and 25534.1 understand thazirthc Wilding
dots not cumen0y Mere a tenant Nat it is my mapomihilifiy o nnuly dte oaeupans of the
immenlswmcm mnu,km❑pnorwismunwo(a CutifinteorCe uponc. Signature of Applicant Date
t�� 6
own, a Ihomsd agen Dam All roof coverings to be Class"B"or better