06120097 CITY OF CUPERTINO
BUILDING DIVISION PERMITCORACT(1R INFORMATION .
BUILDING ADDRESS:
PERMR NO.��/����
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ARCHITECT/ENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
LICENSED CONTRACTOR'S DECLARATION Job Description
or C 1 kmby affirm that 1 am licensed under provisions of Chapter 9(commcMing
;ZUut with Secdon70(g))af Division 3a(the Business send Prarestium Cade.and my license is
y in full race and efr=L n �•
t g( License Class LiIs
c.DECLARATION //
;F� Data Con hatema L//..]� �J�/C C..i C_
£ ARCHITECTS
i C Q 1 understand my plum shall at,until as public rtcords
/'e.lzrr'
'o G Licensed Professional
OWNER-BUILDER DECLARATION
0 C I kmhy.('firm Nat I on exempt from the Convectors e:Lit...Law(or ik
:0C O which following arson.($emion 7(015,Busiair and Plafessiuns CWe:Any city or county
lei which rtquiaa a permit relflai aka ampmsu dech ermitt rie pair any uderma i
thatmor 0irsaiamedpe.also uantto We tkvismapplicant
sof forWe Contratoitmfinarem LacJsnmmcm
- (commeliccnwJpurmammlkpmviviomafofWeBusessaimnxlaw(Centel9 Sq.Ft. Floor Area Valuation
I N (commencing with San 7")add the
Division r of al eg Business and on.fAny vi lation at
� that k is exempt tkallam and tk buis for We alleged exemption.Any violation of
Section 10313 by say applicant far a permit subjects the applicant to a civil penalty of APN Number Occupancy Type
not nam man five huadmd dollars IS500).
1,u awwr o(tim plapcnY•car mY wpioyeu win wage ss me'v sok compewtion.
wad Pr thework,andme ire CoeranatsLic eda Law
doforaak(Sec.to an Business
and Professions who bs Cade The Cammcmrr came Law don fiat appy m an owner or Required Inspections
properywhobuilds i improvestkrwmandwho docssuchwork hi offran through his
bra empb a building
mat suchou iss<manu is m year o d aoRead for sale If,
however,We building carder of pment is sold within ane year of mmponfor We owner-
buildcr ,will have the burden of Playing that k did not build or improve for purpose of
sok.).
❑1,as owner of the property.am exclusively concocting with licensed mntrncm.m
construct the plaject(Sec.7044.Business and Profession Cade:)Tk Cwtaximr's V
cease law dean not.pply to an owner of property who builds or improses Woman,and
who concoers for such platters with a convanor(s)licensed pursmm in the Contractors
Loma law.
ri lam exempt ting/y sec .B&P,C for mar'm^as-on
Owner. (i fi- Daae
WORKERS COMPENSATION DECLARATION
1 hereby alRrn under penalty of perjury fine of the following declarations:
m and will maintain a Cntifiate,of Consent in self-insure for WorkcesConfined.
ma,an provided for by Section 3700 or We labor Cash,for We Performance of the
work for which this permit is issued.
❑1 have and will maintain Workrs Compensation Issuance,as required by Section
3700 of We labor Cade,far We performance of the wool,for which this permit is issued.
My Workers Compensation Wuancc cartks and Policy number art:
Cartier. Polity No.: _
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE .
(Thu section wed not kcomplcied if tk permit is for arc hundred dollar($100)
or loss)
1 certify that an the performance of the work far which this permit u issued.I net fiat
employ any porton in any manwrso�a�m kcrmuubjtt Ne Warton'Comixemseon
Laws of California.fart 33fs�i G+
Applicant
NOTICE TO AP LICAl, IL after making this Certificate car Exemption,you should
became subject in We Workcas Compensxuon provisions of We labor Cade you mesa
.,O raMwdh comply with such Provisions or this Permit shall k decreed naked.
z� CONSTRUCTION LENDING AGENCY
F I hereby SMon mat more is a eomvuetion lending agency for the Performance of
rL > the work fur which this permit is issued(See.3097,Civ.C.)
1 Q lenders Name
] lenders Address
V Q 1 certify that 1 have tend our application and cute mu We akrc information is
Uy f-' Comm I agree to comply with all city and county ordinances and sum laws Missing to
0 til buildingeansuuction,and hereby authoria representatives or this city to enter upon the
purpo
es
Iq
above-cs,judgre property for variation which may
(We)again to new.indemnify and keep harmkss the City of Cupcnina against
h inconseq consequence
egranting oxptnseswhich may in any way scene against said City
(„)Z APPLICANT of UNDERSTANDS
ofthanpermit. �I
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT Issued by: Date 2_-����
SOURCE gFj.Ul.AT70NS.
rte— Z '-20' Re-roofs
Signature car ApplicanuCoalrncbr Date
HAZARDOUS MATERIALS DISCLOSURE Type of Roof
Will the applicant or future building amp.,start or handle haaardom material
as dcfiaed by the Cupenan,Municipal Code.Chapter 9.12,and We Health and Safety
Coda,5ation xssu(')? All roofs shall be inspected nor to an roofing material beim installed.
❑r ON. P P Y g g
Will the applicant or future building wwpant art equipment or lovicei wham If a roof is installed without first obtaining an inspection,I agree to remove
harardnus at contaminants as Jcfned by We Bay Asa Air Quality Mrnagcmcnt all new materials for inspection.
tl?
❑Yu 0 N
I have road We haaaedous materials aquiamenrs under Chip.,6.95 of We Union-
his Health&SefmyCade,Seedons x5505,25533 and 25534.1 undersand mu if We building
dust not currently
cccccc haw a mann.that it is my responsibility m notify the occupant of We
ago'reme h must k met prior m issuance of a CanaOcaw of Occupancy.
- Signature of Applicant Date
Owner aautharimd agent Dam'
All roof coverings to be Class "B" or better