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CITY OF CUPERTINO
_ ° "• �
BUILDING DIVISION PERMIT
�CONTRACORaI*NFORMATI,ON,
BUILDING ADDRESS:
ERMIT"b3120054
""""b3120054
NER'S NAME:
PERMIT ISSUE DATE
.KSNE:
SANITARY NO. CONTROL NO.
ARCHITECrIENGINEER:
BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
0 0 0 0
LICENSED CONTRACTOR'S DECLARATION
Chapter 9
Job D scrlpt�
I hereby affirm that 1 am llcenxd under provisions of (commencing
wile $cation )0!1117 of Division l of the Burin... aM Pmfessiuns Code, antl my lice••• is
��®
in full force and effect.
Cp�pVytwlij
rr I .
License Class Lie. is
Date Crounclar
ARCHMCT'S DECLARATION
(t 7 1 �/ at
MAY 1 2004
I undersand my pians shall he used as public records
sed Pn,fessinn.l
OWNER -BUILDER DECLARATION
BUILDING
I hereby affirm that I am exempt from the Contractor's License Law for the
following mason. (Section 0131.5. Business and Proressions Code: Any city or county
which requires a Permit to construct, alter, improve. demolish, or repairanystructure
poor to its is®anee. also requires the applicant for such Permit to File a signed statement
that he is licnnxd pursuanuo the provisions or Ne Comactori License Law (Chapter 9
Sq. Ft. Floor Area
Valuation
(commencing with Section ]000) of Division J of the Business and Professions Cale) or
that he is exempt therefrom and dw basis for the alleged exemption. Any violation of
3 216S411Frtrber0 0
Occupancy Type
P Y YP
Section 0031.5 by any applicant for a permit subjects the applicant in a civil Penalty of
not more Nan five bandied dollars (5500).
0 1, as owner of the progeny, or my employees with wages as their snit compensation,
Required Inspections
will do the work and me srumum is not intended or offered for sale (See. load, Business
and Professions Code: The Contactors License raw docs net apply Io an owner of
property who builds or improves thereon. and who doeuuah work himself or through his
own employees, provided that such improvements are not intended oroRcred for sale. IL
however, the building or improvement is sold within one year of completion, the owner-
Ndider, will have the burden of proving that he did not Wild or improve for purpose of
ykd
I. as owner of the propeny, am exclusively contracting with licensed contractors to
cpvtmel Ne 'en Ise 7044 Businm and Professions Code:) The Contrxtor's Li
cave raw i t app1Y to an owner of property who Wilds or imprewx thereon, and
who contra s7c..hproje u ilh acenlraemr(s) licensed pursuant to Ne Cenoeeter'a
License La ,
I sm ea pt d•r .B&PCfand, mean
are L
COM SATION DEC ATION
I hereby afnrm under nalt of (jury one of the following decbxmions:
EI have and will maintain a Cenlfic c FCovem to self-mareforWorkersCompen-
mn, as provided for by Smipn 3] of the labor Code, for the perfonnanm of the
work for which this permit is issued.
I have and will maintain Worker's Comperuation Insurance, as required by Section
37W of the labor Code, for the performance, of me work for which this Permit is issued.
My Worker's Compensation Imuance carrier and Policy number art:
Caner. Policy Nos:
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(this section need not W composed if the Permit is for one hundred dollan ($R)0)
less)
1 certify that in the performance of the work for which this Permit is issued. I shell not
employ any perm in any manner x As to become subject o the WorkersCompcnsadon
Laws of California. Date
Applicant
NOTICE TO APPLICANT: If, after making lhu Gif ificare of Exemption, you should
become subject to the Woher s Compensation provisions of the tabor Code. you must
mnhwitn comply with such provisions or this permit sisal he deemed revoked.
CONSTRUCTION LENDING AGENCY
I hereby affirm Nat then is a consouction lending agency for the performance of
the work for which this permit is issued (Sec. 3U91, Civ. C.)
Lem Ates Name
Lender's Address
I certify that 1 have read this application and sun that the above information is
torten. I agree to comply with all city and county ordinances and sun laws relating to
Wilding consuuction, and hereby authoriro representatives of this city to enter upon the
above-mentioned property for inspection purposes.
(We) a me to save, indemnify keep harmless @e City or Cupertino iii
Iiabilida gm .eossandcxpc s hichmaY in anyway seem. againslsaid City
inconseq nccof grand of is mit.
jDate
APPLICA UN E STN WIL COMPLY WITH ALL NON -POINT
Issued by:
SO CE GULAT N
Re -roofs
Type of Roof
UI
gnature of ApP HAZARDO A IA DISCLOSURE Delc
Will the applicant or tutor Itlin mcup anor handle haeardous material
az de(med by the Cupertino �ipal, Ce Ch purr 9.13, and the Health and Safety
Code , sty.2ss3z(a)1 No
All roofs shall be inspected prior to any roofing material being installed.
If a roof is installed without first obtaining an inspection, I agree to remove
Will the applicam or fulure building Occupant use equipment or devices which
emit hazardous air contaminants as defined by the Bay Arca Air Quality Management
all new materials for inspection.
District?
l
C] Yes f9Nu
1 a Nlhe alsreyuimnsunderChaPkr6.95orlheCalifon
riaHe th&Safc Codc5, 25577 and 25534.1unrlersund thmifthc Wilding
FL131'
does n t cureody ter is my responsihility w notlfy Ile occupant of the
mqui edL whieh sW l u C .CRtlflcaug.f Occup \Y. `t)
Signature of Applicant Date
5
All roof coverings to be Class "B" or better
owns.edageml ales
V V