04110057CITY OF CUPERTINO
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- PERMIT
�CONTRAC�TOR�INFORMATION
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BUILDING DrvlsloN
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BUILDING ADDRESS:
PERMIT NO.
04110057
iP1YVA1�1H-LS'1'UPERMIT
ISSUE DATE _
E
SANITARY OL NO
ARCHITECffENGINEER:
BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
LICENSED CONPRACTOR'S DECLARATION
Job Description
I hereby affirm No I am )Emitted under provisions of Clopier Y (commencing
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wilhSmtian7")ofD '"13af NcBw,nucwand profcssbm Codef.antlmy but. is
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in full forand offm
a l.
License Class Lie.0
STORAGE @ GARAGE (3) (231 SQ FT.)
Doc Contractor
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ARCHITECTS DECLARATION
I tnderaund my plans shall the used as public records
'- •" - "—
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Licensed Pre cesi...I
OWNER -BUILDER DECLARATION'
I kmhy affirm I am exempt from Nc CssionstC License taw for the
following on ]Isbsr Business andCWc:Any city or county
-
en. foram
which permit re construct, alar, improve, demolish, or epsig any suucmre
which nexuses a
e. skis
pilar m ill issuance. atso requires IM applicant for such tennis mi Ic a signed sutemem
the
Sq. Ft. Floor Area
Valua
that he Lianx Law (Chae)or
wit pumsanitoN)pravisionsm den.
B.aacmn's
homforiaid, Code? or
baDivision3 ofaleged essandon.
(commencingwith Smlfro
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and Any vi
' Nal he Is exempt therefrom and bac, hadfor the alleged exemption. Any violation of
,
- ppjj_�j1'yg,y,�,r
Occupancy Type
section ]WLsby.nyappfe,nlfor .pemeitsubjeeutom applicant 1..&H cndl,of
not more than fin hundred dollars WWI
3 4 ZZ S 4'D S b . 0 0
I, as owner of Ne pmpeny, m my employco wish wages a Ncir sole compensnlon.
Required Inspections
will do Ne work and Nestmnue is not intended unripened formic(See 7W. Busin...
and Profession Code: The Co eraclor's Liana[ Law doa not apply to an owner of
-
property who buildsmimprow themon, andwho doessuch work himself or through his
own employees, provided that such improwmenu are n itinunded oroRered for sale lf.
however. Ncbuilding orimpmwmensissoldedidnot year or aporn(of Neowned
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Wilder will have Iht Wrdm of proving Nn be tlitl not build or impmw (or puryuse of
/
mm m
1. es owner of ct property, . B exclusively contracting CiN:i TheC Contractor's Li -
c Lmm project(Sec.o andrtywhoorsCode:)The Conuacmi.
O
J
an owner of dd
c. x Law docs nos apply je an owner of pmp[ny who Wilds or improves thereon, add.
d
, - _ . _ ,__ - _who
contracts for such projects with a contractor(s) licensed pg swam so the Contractor'sLicense
Law.
ea n r5[c ,B&Pcfo N u
of ;`�Owns
WORKER P SATIO OEC ATION
1 hereby afford under Penalty of perjury ane of Nc following olmlantiores:
haw and will maintain. CeNfiate of Consent W self-irembe Tor worker Camper-
-
salied, u pmvide0 for by Section 37M of the IaWr Code, for the Petition.. of the
work for which Nis pn an is issued.
❑ 1 have and will maintain Worker's Compensation Insurance, as nyuired by Section
37W of the Labor Code, for the Performance of one work for which this permit is issued.
-.
My Worker's Compensation Insurance carrier and Policy numkr am:
Carrier: Polity No.:
CERTIFICATE OF EXEM MON FROM WORKERS'
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COMPENSATION INSURANCE
(Thus section need nos he completed if she permit is for.. hundreAdnllan (SIM)
or it .)
1 certify Nm in the performance of N[ work par which this Permit is issued, 1 shall not
eroploy.ny Eamon In any manouran a5 to became subjeel to the Worocri Cone iallan
Laws of California. Dale
Applicant
NOTICE TO APPLICANT: If. after making this Ccnificate of Exemption, you should
beam[ subject to the Worker's Compereenum previsions of the labor Code, you must
fonbwish comply with such provisions or this Permit halt W deemed revoked.
CONSTRUCTION LENDING AGENCY
nn lending agency lank performancc of
that mere ill cid
1 herebywhich
'
(See
' tate wish for which Nis penis is issued (Sec.11197, Civ. Cd
Led,1 sNamc
Lendcls Address
I comfy that 1 ban rad this application and sure No Nc soon information is
'
' correct. I agree to comply with all city and county ordinances and suis laws relating to
building cmuwnion. and hereby authentic repreaentasiva of this city to enter upon Nc
above-mentioned property for inspection purposes
(We) agree to ann, indemnify and keep harmless IW City of Cupertino against
liabilisies,judgmenu, coati end ex esw and in in any way accrue .,inn said City
in cone cc of them t t il.
got per
q AP A UNDER S D IL LY WITH ALL N N INT
Issued by: Date �' p
E GULATI
`
Re -roofs j
Type of Roof
reo Pelican uGOE .te
AZS MATE RIALS DISCLOSURE
ARODU
Will the or future building occupant core or handle h malmim
eallous
Cr defined me Cupertino MuniciMl Cade. Chapter 9.I2. and Ik Health and Safety
a Cupertino
Code, Section 25533(.)7
io
All roofs shall be inspected prior to any roofing material being installed.
❑Yrs No
If a roof is installed without first obtaining an inspection, I agree to remove
Will Nc applicant or fist c Willing occupant use cyuipment or d<vices which
L hazardous air cordon nu defined by the Bay Area Air Quality Management
all new materials for inspection.
sensed
yce Nu
I have mm the but thins on.ialsrtggqpppI on haper 6.95 ofmc C411for,
ria Healon sycodc, sectio SB5,25 ad , dcrsuM dwifthe Wilding
docs cu n y hast a ten L ex novyf en notify the oceup I or the
e wennot st�m r a terra[
Signature of Applicant Date
All roof coverings to be Class "B" or better
0 e at umodacd.g til Data