04020139 CITY OF CUPERTINO �'
BUILDING DIVISION PI✓ IMIT 4CONTRACTOR',INFORMATION
BUILDING ADDRESS: SAMUEL CONSTRUCTION PERMIT NO 04020139
OWNER'S NAME: PERMIT LSSUE DATE
SUNNYVTRW LUTHERAN HOME 1497 FLORAUTq7A A172 02-41 9 l ?QnA
JNE: SANITARY Na. CONTROL NO.
408 24 -
ARCHITECl/ENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
0 0 0 0
LICENSED CONTRACTOR'S DECLARATION
YmF I hereby affirm that 1 am licensed under penvisons of Chapter 9(commencing Job Description
<Z�a with Sation 7rs(lU)of Division3of the BusimssandProfeta.n Code.and mYliernxis �-
n« in full force and cR ✓
5'q= IimaxCaa� tie.« 5G5� J72- REVISIO -IN HOUSE USE ONLY
�—o Oax contractor W RMIT ISSUED ORIG. #03080181
j U e ARCHITECTS DECLARATION
I undCS rad my plans shall he used as public records
u
Licensed Pmfcssional
x'05 Out I am exempt fr DECLARATION el
0 0 I hereby affirm this I . exempt from the fessins Co license Law for ted
o O following maw.. Pani.1 t(l3 mo Business and ova,de Professions Cale:Any city Of county
which reyvires a permit m cnnswn,alum impmw,demolish,or repair any umnum
prior m its issuance,aku requires the applicant for such permit in file a signed statement
izcthat heisficcnsedpursuant to the provision ofthe ConfusionLw<nxLaw(Chapter 9 Sq.FL Floor Area Valuation $0
01-M
~ (commencing with Section 7000)of Division 3 of the Business and Pofcasions Code)of
.. that be is exempt therefrom and the buts for the alleged exemption.Any violation or
Section 70313 by ary applicant for a Permit subjects the applicant to a mil penalty of APN Number Occupancy Type
not more than five hundred dollars S500).
P y yp
❑1.as.,of the preperty.ar my employm iN wages as their me aampenudon, 32615130 . 00
will do Ne work,and the mixture is not intended or offered for mak(Sec.7060.Business
and Professions code:Tom Coniwoes License Law dors not apply to an owner of Required Inspections
propcny,who builds or improves thereon.and w ho does such work himsel f or though his
..employ=.provided Nat such irepmsemenu are not intended moRered for sale.IL
however.the building or improvement is sold within one you of completion,the owner-
builder will have the Wrden of proving But he did not build or impow for purpose of
Is).
1,as Owner of the property,am esclusively contracting with licensed Conbxtors x
.as.,the product(See.1610.Business and Profetion Code:)The Contractor's V.
nK Law does not apply to an Owner of property who Wilds or improves thereon,and,
who contracts for such Projects with a conrxmr(s)licensed pursuant to the Contractors
License La .
lamnempttndm Sea .Bh PCfm Nisrcaxn
Owner Data
WORKERS COMPENSATION DECLARATION
t 1 hereby affirm under penalty of perjury,ane of the following declarations:
1 hale and will maintain aCerdficate of Consent in self-insure for WorimesCompcn-
sation,as provided for by Section 3700 of the Labor Code,for the PeRmmancc of the
week for which this permit is issued.
1 haw and will maintain Worker's Compiu ation Insurance.u required by Section
3100 of thc tabor Code,for the perfmmame Of the work for which this permit is issued.
My Workers Compensation In.omce Carrier and Policy number
Cartjar'�+'i+ PONY N am: S
OMWORRKERS'
CERTIFICATE OF EXEM
COMPENSAII RANCE
Cr iessection need not W completed if the permit is for one hundred dollars(SIM)
in less.)
1 certify that in the perfo mance Of the work for which this Permit is issued.I shall not
employ any person in soy insurer w as m become subject to the Worker:Corepen itlon
Laws of California.D.
Applicant
NOTICE TO APPLICANT:IL after making this Ccmficau of Exemption,you should
become subject to the Worker's Compensation provisions of the labor Code,you mum
.,O foMwiN comply with such provisions or this permit shall be deemed mmkcd.
Z�y CONSTRUCTION LENDING AGENCY
I hereby affirm Nat there is a construction lending agency for the performance of
0: Nc work fur which this permit is issued(Sec.3097,Co.C.)
a0 Undoes Name
=z Lender's Addrw
U C) I certify Nat I have read this application and sues that Oc above infoonatiun is
IT. F correct.I agree to comply with all city and county ordinances and slate laws relating to
0 Wilding Construction,and hereby auNorim represenliives of this city in enter upon thc
�a abovcmentioned property fa inspection purposes
(We)e,me Io save,indemnify and keep harmless the City of Cupertino agoinn
liabilities rudiments,costs and expenses which may in any way accrue against said City
U Z in cosaqucmc of the grant.,of this Knott-
APP APP ICANi UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT Issued by: Date
SO R REGULATIONS. %O�
Z-Aay(-a4 Re-roofs
Si mune Of Ap UCO Data
H SMA7FRIAISDISCLQS Type of Roof
Will the applicant or future building occupant see hvndousmauriil
as defined by the Cupenin.Municipal Code.Chapter 9.13,and Ne Health and Safety
cwe.s«dnnus3zca)1 All roofs shall be inspected prior to any roofing material being installed.
❑Yes �N.
Will the applicant or future building occupant use equipment at devices which If a roof is installed without first obtaining an inspection,I agree to remove
at hamrdous air c.maminants es defined by the Bay Area Air Quality Management all new materials for inspection.
Duvic4 J
❑Y 6k
I have read Ne hanWoussmmawHals mquiomenu under Chapter6.95 of the Califor.
nim HealthurSafetyhawaSection 35X)5.25533and SSS3a.l 0hod he
Occup Wilding
docs not currently haw•unwa Nat it ts my imputability b irotify Ih.occupant of the
requirementswhichMUSEWMCIP'orwissuaneeOf2CertificateOfOceaaney Signature of Applicant Date
�ja�Y m 14�e All roof coverings to be Class"B"or better
Owner or authorized agent Doc