04080200 CITY OF CUPERTINO " �
BUILDING DIVISION PERMIT ' CONTRACT
riAORINFORMATION 4
BUILDING ADDRESS: PERMIT N0.04080200
OWNER'S NAME: PERMIT MUE DATE
HPL
SANITARY O OL NO.
ARCHITECT/ENGINEER: - BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
0 0 0
°00 LICENSED CONTRACTOR'SDECLARATION IobDescri tion
i u C I thereby affirm tbe,I am licensed under provisions of Chapter 9(commencing p
szw with Scmion]0I1o)of DivoJ.n3of NCBuv'nen.+fart'�dP/ro�fcsqsinns Codec,end myliecnu is
in folk(omJ and cflccl2 1L�1'r/�f��
jai Licensa�Gt ,// Lic.N TI--MODIFY CONCRETE & ADD EXIT DOOR
�— Conveccr GNN/Gfa yG17f
� a ARCHI"IECTS OECL�ON tt�� p /�S
�iu,Q Ion crsund my plans shall be uscdazpuh'e Js ��B tltl tl��®
�a v � t'tJlp�a Iltf'I
o G Licensed Pmfcuional
OWNER-BUILDER DECLARATION
I hcmhy affirm Nm I am exempt from Ne Convacom's License Law for the
o 00 following moron.(Section](131.5.Business and Pmfcamms Codec:Any city Or county ry
K$I which 2gaima a Permit 1t'construct.Bluer,Improve,demob.sh,or repair any Stracome �ua r I Inn
''u—'^ prior m its issuance.also requires the applicant for Such Permit m File a signed summons .Ura
2nthathcislicensedpursuantmtheprovisioosofNcContrxtor'sU.. aw(Chapter9 Sq. F[. Floor Area Valuation �
tet- (commencing with Section of Division 3 of the Business and Prefessinm Code) t{p e,1 11 A e W
i R S that he u exempt thcmfmm and the basis for the alleged exemption.Any violation of w�fiL�J�I tl 11 II
Secdon 7031.5 by airy application for a permit subject me applicant to a civil penalty of .3�V1gnD t>Ieai;QJd I1 P1� 11(t Occupancy Type
not mom man five hundred dallan($5001. YA-aw p`f 7f T�,g
1,as owner of he property.or my employees with wage u their role compensation,
will do me work.and en stmcnure is notintendcd cr offered far gale(Sec.7W.Business
and Professions Cade:The Contncmri License law does Out apply to an owner of Required Inspections
pmpeny who builds or improves daemon,and who doossuch work tonsillar through his
awn employees,provided dint Such improvement arc not intended or offered for We.If. -
howeve,the building or improvement is sold wohin me .of completion,me owneo-
builder will have the burden of proving but M did not build or improve for purpose of
Sale.).
❑1.as Owner of the progeny,am exclusively convecting with licensed comeacmre to
construct the project(Sec.]Baa,Business and Professions Code:)The Commuc m's Li.
came law does not apply to an owner of property who builds or improve daemon.and,
who connote,for such projects with,a cantnctiou)licensed amount to he Connoctars
License law.
❑1 rem exempt under Sec. ,B&PC for this reason
Owner Dow
WORKER'S COMPENSATION DECLARATION
1 hereby affirm under penalty of perjury..of the fallowing declaouons:
have and will maintain a Certificate of Consent to self-inaum for Worker's Compcn-
serum.as provided for by Section 37W Of the labor Code.for me p honor en of the
work for which this permit is issued.
0 1 have and will maintain Workers Compensation Insurance,as recruited by Section
37000 of me labor Code.for me performance of the wark for which this remain is issued
My Workers Compensation Insurance emier and Policy number me:
3TpT4 F(JA13) Poy'v/No.: 10 5 A�23
CERTIFICATE OF EXEMPT FROM WORKERS'
COMPENSATION INSURANCE
(This section need not he completed lithe permit sermon.hundred dalurs(5100)
nr less.)
1 cmify mat in me performance of to work for which this permit tissued,I shall nut
employ any person in any manner u as m become subject to he Workers'Com mustation
Law s of Califomia.Date
Applicant
NOTICE TO APPLICANT:If,after making this Certificate of Exemption,you should
become Subject to the Worker's Compensation previsions of the Lahor Code,you mast
.JZ faMwim comply wire such provisions or this Permit shall be d¢meJ revoked.
Z U; CONSTRUCTION LENDING AGENCY
PI hereby affirm that incm is a communion lending agency for the Performance or
[L me work for which this permit is issued(See 3(19].Civ.C.)
Igl Q Lender's Name
G Lender',Address
Z
U O 1 certify mu I have read this application and sum Out the about information is
W F comm.I agree m comply with all city and county ordinances and sum laws relating to
�U building conswction.and hereby aathomerepresenutives Of his city to enter upon the
W above-mcnam rcd property for inspection purposes.
gy (We)agree to save,indemnify and keep harmless he City of Cupertinoagainst
Fti IiabiliJa,judgmemt,costs and expenses which may in any way see=against said City
U z APPLIC seethes Of me NDERSTung Of At D WILL COMPLY WITH ALL NON-POINT Issued by: Date
SOUR T
Re-roofs
Sgyoluac or ApplianJContm on m
HAZARDOUS MATERIALS DISCLOSURE Type of Roof
Will he applicant or future building occupant store or handle haordous material
as defined by the Cumnino Municipal Codec.Chapter 9.12,and he Hcalh and Safety
Calc.Suction 25532(.)? / All roofs shall be inspected prior to any roofing material being installed.
❑Yes PNo
Will the applicant or future building Occupant use equipment Or devices which If a roof is installed without first obtaining an inspection,I agree to remove
t hazardous air contaminants as defined by the Bay Arca Air Quality Management all new materials for inspection.
nviclT • /
❑Yes Ils-d'-qu
1 hove mad the haiardous maerialamquimment under Chapter 6.95 of he Califon
nia Hcaltb&SafayCode,Sections 255(15,25533 and 25534.1 understand datifmc Wilding
does mol curt• tly M1ave ejp n Na t is my reapnmibda,m noufy the occupant of he
¢yvimm Mamm�(bcmet ��teilluanecoraccoifieamofOccapis Signature of Applicant Date
c'� x �/ All roof coverings to be Class"B" or better
Owner mhorircd agent _ Da¢