04010130CITY OF CUPERTINO'=
z
BUILDING DIVISION PERMITCIDNTRAC�TORI�NFORMATI�ON�F,',
ING ADDRESS:
PERMIT N'04010 130
R'S NAME:
iE
PERMIT ISSUE DATE
0-1 12 1112
PHONE:
SANITARY NO. CONTROL N0.
ARCHITECTIENGINCER:
BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
o 0 0
LICENSED CONTRACTOR'S DECLARATION
Job Description
I a under provisions of, (commencing
I hereby affirm that 1 am
P
Coder n
Division J of the Burin... and Professions Coec, and my liccns is
withSeminarto. 7") Bu
of be
in effect.
dof ec
REVISION--IN HOUSE USE ONLY
Lima. classnJ
Lica
Dam Contractor
.
NO NEW PERMIT ISSUED/ORIG. 403120054
ARCHITECTS DECLARATION
PS
1 understand my plans shall be used ka puhOc reroms
J Professional
OW NEE-BUILDER DECLARATION
1 hereby affirm Nm 1 .m cBcmpe the Coru License Law for the
Code: Any city or comedy
following moon.(Senium 703L5, Business and a Co :
reaso s a
dermm
which requires a permit re cunswn, ,iron improve. demob itu or repair any suticmm
improve.
prior a is l ceased p also requires to the the applicant fur such permit t0 Glc a signed statement
Nm he in licensed pursuant to Commness
Sq. FL Floor Area
Valuation $0
of DivionsnMc niarlaw(Chaptm9
(commencing with hereon of Division J Cmld or
Business arta Proon.
that
he is and al Any
li and Ne breis for the alleged exemption. Any vimmiay of
WI he is the
APN Number
Occupancy Type
1.5 b any applicant
p
Section byaundreddollar
IapcsmiuubjccsNcepplicanuaacivilpenaltyof
not
not more than five hundred dollars (1500).
P Y YP
01, as owner of the pmpcny, or my employees with wages u their. rule mompematien,
32634074.00
Required Inspections
will do Ne work. and thcswnum is not inendce or offered forsa1.(Sec.7W. Business
and Pmfessims Cade: The Conuacmr' Liar law does not apply a an owner of
property who bands m improves Nemon..nd who does such wart hf rm,lCmdomigh his
own employees. provided thatsvch improwmenks are not imended moffered for sale. If.
however. the building or improvement i. sold within arc you of emople ion. Ne owocr-
builder will has the burden of proving Nat be did not build or improve for purpose of
sale.).
/
1. as owner of the property. am exclusively com.cting with liard contractors to
o sten In, project (Sec. roux, Business and Professions Code:) The Contractors Li.
(�
terse law d t apply to an owner f ropeny whir builds of improves Nerton, and
who comm fors ch pro, 'Na a units) licensed persuam I. NC Conuanar'a
Liven¢ V .
slam eze ps and ,Bk PCfor is
Da¢
E OMPE ATI N DECLARATION
c
I hemby alNm node Ity of rju one of the colla latwous:
❑ I has and will maintain a Ce ihcae of ore m sell insure fm Wmkcrs Compcm
sation, as provided for by Section 3I00 of the Labor Code for the performance of she
work for which this permit is issued.
❑ 1 has and will maintain Workers Compensation broomime, as required by Section
PUB of the labor Codc, for thc performance of be work for which this permit is lattice.
My Workers Compensation Insurance artier and Policy number art:
Cartier. Policy No.: _
CERTIFICATE OF MM MON FROM WORKERS'
COMPENSATION INSURANCE
(fibs section aced not he complewd if the rrrmit is ford rc hundred dollars (SIM)
,
in IcssJ
1 certify that in Ne pe,lomurme of the work for which Nis permit is isssod. I shall or
employ any person in any manner un n In become subject o the Workc W Compensation
Laws of Califurno. Dam
Applicant
NOTICE TO APPLICANT: If, after making Nis Ccmfi,rm of Exemption, you should
become subject m the Warker's Compensation provisions of she Labor Cede, you must
fonhwiN comply with such pmvisions to Nis permit shall be deemed revoked.
CONSTRUCTION LENDING AGENCY
I hereby affirm that there is a emntmetion lending agency for the performance m
the work for which this permit is issued (Sir. JIAT. Civ. C.)
Unders Name
Lender's Address
I certify that 1 has rad Nis application and some that the show information is
COMM l agree to comply with all city and county ominances and sate laws aiming to
building eonsvuaion, and hereby authorize aprescr atives of his city to enter upon the
abor>memioned property for iaspecuan purposes
PQr.ped m saw, indemnify and keep hasml. the City o(Cupenino against
liabili ea. jud mons. eta e a s which may in any way remove against said City
cf
ineu quen[ of}hell, reit.
✓/f
APP CA UNN E hi COMPLY WITH ALL NON-POINT
y
Issued by: Date U
SOU ER GU
l
Re-roofs
nurc ONAVOica ser Dam
HA OUS TE ALS DISCLOSURE
Type of Roof
Will the applicant f rob Iding cupamsmrc or M1andlc h.vardous material
`
u defined by the Cupenina unici I C .Chapter 9.12. and he HeaIN and Safety
SeNon 255]2(.)?
All roofs shall be ins ected rior to an roofin material beim❑yes P P Y g g installed.
If a roof is installed without first obtaining an inspection, I agree to remove
Will the applicant or future building=upon, r equipment or devices which
hazzmnus air contaminants as defined by the Bay Area Air Quality Management
all new materials for inspection.
ict?
❑YesI
I
hav ad Ncharr uimmensundcrChapar695oftheCalifor-
cxlthSafctyLak,JJard255Ja.lun&msm miflMMiilding
endy haw a poraihilitybmUfythea<up.ntofNe
smor theumtro,
men which t ofacmni
Signature of Applicant Dale
` pate
All roof coverings to be Class "B" or better
ownmmaamor;.ed.g t