05030238CITY OF CUPERTINO7��4
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BUILDING DIVISION PERMIT
3 COiVTAXOTORRINFORyMATION
-
BUILDING ADDRESS:
CAL CONSTRUCTION
PERMIT NO.
05030238
OWNER'S NAME: -
PERMIT ISSUE DATE
iE:
SANITARY OL NO.
ARCHITECT/ENGINEER:
BUILDING PERMIT INFO
BLDGEI.ECf PWMB MECH
E 0
LICENSED CONTRACTOR'S DECLARATION
Job Description
1 hen:by affirm Nal 1 am licensed unser provision of Chance 9 tomprom ting
_ p
with Section 7IXM)) of Division Sof 1W Business and Prolessions Coda, and my license is
Licenlse to= erfeeL L].g
REVISION --CEILING
Dam Contractor
NO NEW PERMIT ISSUED/ORIG. 404100179
ARCHITECTS DECLARATION
1 undersu til my puns shall be used as public me.,&
Licensed P.(cui... I
OWNER -BUILDER DECLARATION
1 hcrehy Ifirm thm I am nempt from the Contractors License Law far the
following mason. (Section 7031.5. Business and Profession Code: Any city or county
which propo n a Permit to construct, slur, improve, demolish. or repair any structure
prior to its issuance. also requires the applicant for such Permit to file a signed stammer
that he u licensed pursuanua the provision of the Conuxtari Lim. law(Chapter 9
Sq. Ft. Floor Area
Valua[i�n115
(commencing with Section 7000) of Division 3 of the Business and Profession Code) or
that he u exempt licentious and the buts fm It. alloged csemption. Any violation of
APN Number
Occupancy Type
Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of
not mart than five hundred doll. ($SW).
❑ I,asownerofthopmNan wmyemploycnwithwagnutheirmlccompenadon,
36225002.00
Required Inspections
will do the work and the stru tme is not inended oroffend (ouch (Sac.7(14. Business
and Profcusi.n Cox: The Conrraators Lune law dw not apply to in Owner or
property who builds., improwa Nen on, and who doessuch work himself ortMugh his
Own employers, provided that such improwmcnu an not intended or offered for We. IL
however, the Wilding or improvement is sold within ane year of completion. Ne owner.
builder will have that burden Of proving that he did not Wild at improve for purpose or
aalC ,
f
I. as owner of the property. am eaclmively contracting with licensed contractors to
construct meit project (sec. Business and Cade:) Tho C
nalsWilds
t tormon. raLi-
ry who and
at of Dmpeny who
ttve law tlon not m an
.
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__
inwt Conn.
who contracts for such pmjccu with a conuacwrp) littrucd Pursuant b the Conuactofs
witha sed pursuant
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License law.
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❑ I amemmpluder Se c. .Bk PC far A noon
Owner Date U
ORKER' COMPATION DECLARATION
I hereby affirm unxrperWty. ,jury araC of the fallowing declanion:
haw and will maintain a Cimlicae of Consent to xl(-insun for WorkersCompen-
n, as provided for by Section 3700 of the labor Code. for Ne pmmornentt .f the
work for which this permit is issued.
1 have and will maintain Worker's Compensation Insurance, as repaired by Section
3700 ofthe Labor Code, for the performance of the work for which this permit is issued.
My Werkcrs Compensation lissom arricr and Policy number an:
C.mcr. Policy No.: _
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(Thissection need not completed if the Permit is foranc hundred dollars ($IIX))
or less,)
1 certify that in the performance of she work fo which this permit u issued, I shall not
employ any parson in any mMuO, sm as in til CCa }IC'WOrke.,cmapensatian
Laws of Calif n Date
Applices
NOTICE TO AMLICA. 1 , after n kinj Lgmir�'ilctuc of Exemption, you than]]
r
kmare Subject to the Worker's Co "ration previsions of tht labor Code, you all
forthwith comply with such proviai s or this permit shall be deemed revoked.
CONSTRUCTION LENDING AGENCY
I herby off do, dam rm Nm there is s' See inn lending agency for do perfurman¢ of
the wort which this permit is utued cO (Sec. 3097. Civ. C.)
Lender's Name
Lender's Address
j 1 cenifr Net 1 have mad Nis end sun that the above information is
coned. 1 agree a comply with all city and county ordinances and sum laws relating a
henbyaehorixrsiva of Nis city menet upon the
haroa relo
ithavengconsuuaproend
t shave-mcMonW property findmnify
ankeeppurposes.
(We)agreeto save, indemnify andkeepharmkv the City of Cupertino against
ii
j inconsusucirm en¢eassand of% is Pswht. may in any way tient againsuaidCity
i APPLIyucncc of trng of NisD mil
APPLI NT UN STANDS AND WILL COMPLY WITH ALL NPN -POINT
Issued by: Date
SOU EREGUL S. r1O
1 t v
hl
AAhX�
Re -roofs
Type of Roof
Signatiche of ADPlic utContanselor
HAZARDOUS NVATERIALS DISCLOSURE are
dous aterial
Will that applicant or future Wilding occupant tin oor handle hisum
as defined by NC Cupenino Municipal Coda, Chapter 9. 12. and the Health and Safety
C. section 15533(.)?
All roofs shall be inspected prior to any roofing material being installed.
❑Yn 6,4Will
If a roof is installed without first obtaining an inspection, I agree to remove
the applicant or future building occupant use equipments devices which
haramnus air canuminanu dcGncd by the Bay Arta Air Quality Management
all new materials for inspection.
icO
D Yes Nu
I
1 have mad the hxrardousmedals requirements underChaper 6.95 ofthe Calirm.
ealth h SafetyCode. section25505, 15533 and 25531.1 understand Nazirdre Wilding
notcornntly haw enant, that it u my mironihility w rustily the Occupant of the
ucmcnu which mu mat prior w issuance of a Ccmfine of war.
Signature of Applicant Date
All roof coverings to be Class "B" or better
Ow
ner ar a homcJ egcnt a�