02120085 CITY OF CUPERTINO - "-
BUILDING DIVISION PERMIT CONTRACTOR INFORMATION
BUILDING ADDRESS' r, PERMIT NO. _
1o161 De Ahzo. Ri«A . w Si p\s �tn � 02 Z0 �BS
ER'S NAME:,/, APPLICATION SUB DATE
19Jy 6`^^ 2 Z, Z V O Z—
PHONE:( t v SANITARY NO. CONTROL NO.
�3y-� - ISS
ARCHITECT/ENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
Soo LICENSED CONTRACTOR'S DECLARATION JobDescri non
1 hereby affirm that I am licensed under previsions of Chapter 9(commencing p
with Section 7000)of Division 3 of NC Business and Professions Code,and in,license is C
m os� a x
" umenmclaaa Lie.« '13349
OZ— Pare T'S DECLARATION F=
ARCHITECT'S DP,OLARATION
I understand my plans shall be used as public recordsapdG
LLo Licensed Professional
OWNER-BUILDER DECLARATION
0 E I hereby aflirm that 11. exempt from the Contractor's Co License law for the
w ❑p following remora.(Section]031.5, t,alter, mp ve.demolish,
Code:Any city or county
e. $(L which requires a permit ac umasrum,alter,improve.demolish,err repair any¢Oucmle
�^ poor toat he
issuance person requires mcersionmt for soh pctminoear.gm(Chaptcm
I—?< (comm lading wit pursuant mthe of Division
of dm Contractor',nsland Pnselaw(C Code)or Sq. Ft.Floor Area Valuation
'at
(commencing Section 7(n))the
Diaiiiofrnf(Meged Businessland Any
Code)or
Net be u exempt Ihcre(rom and Ne brei for the alleged exemption.Any viola0on of
Swoon 1031.5 by any applicant for a permit subjects the applicant to a civil penally of APN Number Occupancy Type
not more Nan rive handled dollars($500).
0 I.as owner of the,property,or my employee,with wages as droit aolm compensation,
will do the work,and 0th structure is notintended or offered for sale(Sm.7044.Business Required Inspections
and Pro(esslones Code:The Cono-mmim la
s Lieco w does not apply to an owner of q p
propenywho Wildsor improve thereon,and whodaessuch work himsslforthrugh his
own employees,provided ma such improvements an,non intended orn0ered for We.If.
however,the building or improvement is mid within atm year of mmpledon,the owner
builder will have dm burden of arming Our be did not build or improve fur purpose of
sale.).
0 1,as owner of the property,am exclusively comracting with licensed commcmm to
construct the project(Sec.7044,Business and Professions Code:)The ConuactoYs Li.
redue law does not apply in an owner of proPeny who builds or improve¢thereon,and
who contracts for such projects with a contractor(s)limnsed purswns to the Contactors
License Law.
❑1 am exempt under Sec. .B&P C for this memo 1
Dam
WORKER'S COMPENSATION DECLARATION
I hereby affirm under penalty of perjury one of the following declarations:
0 1 have and will mammon aCeniftcate ofConsem calf-inure,for Workers Compere
sa(ion,as provided for by Section 37M of she labor Code.for the perrimer.a of the
.,it for which this permit is issued.
0 1 have and will maintain Worker's Compensation Insurance,m required by Section
3]IX)of"lot Cork,10,me performance of the work for which this permit i¢issued.
M er's�Csnm moignlnmramm carrier end Policy�naum�ber.r1l.,
Cartier. S :I Policy No.:` 1 CC 11
CERTIFICATE OF EXEM PTON FROM WORKERS'
COMPENSATION INSURANCE
(Thkasection need not bacompleted lithe permit is for one hundred dollars(5100)
,it less.)
1 certify that in the perlinm race of the work for which this permit Is iaucd.I shall not
employ any Person in any manner or m In become subject to the Workers'Compensation
Laws of California.Data
Applicant
NOTICE TO APPLICANT:If.after making this Certificate of Exemption,you should
become subject to the Workers Compensation provisions of the LaMar Code,you mus(
OO forthwith comply with such provisions or this permit shall he deemed revoked.
y CONSTRUCTION LENDING AGENCY
t.. I hereby aflirm that there is a construction lending agency far the performance of
a
the work fur which this Permit is issued(Sec.3091.Civ.C.)
QUnder's Name
.7 z Lenders Address
U I unify Out I have mad this application end sum that the above infosmafirm is
D. H correct.I agree to comply with all city and county ordinances and state laws relating to
OU building construction,and hereby authoria,mIusenttivee of this city to caner upon the
W .1mve-mentioned property for inspection purposes.
L (We)agree to ave,indemnify and keep harmless the City of Cupcnino against
In liabilities,judgment.costs and expenses which may in any way acemc against mid City
U Z in conscqu "dW granting ofthispermit.
�--� APPL NT UNDERSTANDS AND WILL COMPLY WITH AL NON-POINT Issued by: ate
S EGULAT ONS.
Re-roofs
nature o(Appicent/Contoctor I Dam
HAZARDOUS MATERIALS DISCLOSURE Type of Roof
Will me applicant errfuture budding(c i stare os handle himdous mown.)
m defined by the Cupenino Municoipal .ChaPmr 9.12,end the 11ea0h and Safety
.Section 25532(x)? All roofs shall be inspected prior to any roofing material being installed.
0 Ye
Will the applicant or future buddin ant use equipment or devices which If a roof is installed without first obtaining an inspection,I agree to remove
emh hzrardeus air contaminants as it by the Bay Area Air Quality Management all new materials for inspection.
District?
E]Yea No
1 have mad the hi Moos mamUels requiremmnks under Chapter 6.95 of the Califon
ria Hcal cry Cask.Secdom 25505,25533 and 25534.1 undsrstnd mat if dm building
drainIN curlemly hate a mnm0 mat itis my rcapumiM1ility m ramify(M mcupm(of the
re mens,which most N in tin isamncmofaCerdficamofacparty. Signature of Applicant Date
slea� � -%.o ° All roof coverings to be Class "B"or better
or eurbanized agcm Dam