05020031 CITY OF CUPERTINO %r•. *:-w' +^son's%?;»� rs- � "z.:i. xsi
BUILDING DIVISION5 � OR INFORMATION :••.
PERMIT CONTRACT �
BUILDING ADDRESS: 111111,190
5O2 O O31
OWNER'S NAME: PERMIT ISSIIE DATE
E; SANITARY NO. CONTROL NO.
ARCHITECDENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
0 0 0 0
uo0
LICENSED COMRACTOR•SDECLARATION I IObDeSCrIIOn
� F❑ I lereby affirm Nat I am Iicereed under provisions of Chapter 9(commencing p
iW with Section 7000)of Division 3 ofthc Business and Professions and my license is
in@B foneanE effect. -7�Ut nsTI--RELOCATE DOOR
S�? Lkcnsc lass Lic.g
Zrw Dam — Covidoor CONTRACTOR: METHOD CONSTRUCTION
ZZ A rtEC1'S DECLARATION
K do n y plan 1 be used as public records
�yU
Liccn mfcssional
3 dr E.exempt
DECLARATION
.�00 I hereby alum Nal 1 1. aempt from Nc Conuuroo e:Any
city
o for she
OO followingures a.Permit
]roil tr t.alter andmp Pm.deVOMCOde:Any City areounty
ctur,
m which its issuance,
n tremor m moos doe elme impmsu demolish,or repair any swment
prior m its censeac,alsor rsuarequires IW applicant for such permit to Glc License sopa(summons
t1-
that
SFOcommed,wJpursuanu000)ofviviomofthcGusincounPrLaw sime,C .)or Sq.FL Floor Area Valua(d 12OO
(commencing with Scosion]UflO)of Division Jnithc Busineuand Profassinns CM.)or
W Nat he is exempt therefmm and the basis for the alleged ewnpidon.Any voided
on of
Section]031.5 by airy applicant for ape.I,subjects the applicant in a civil penally of APN Number Occupancy Type
not mare tun five hundred dollars($5O0). 32634071 . 00
El 1,m owner Of the propcny,or my employees wile wages as their sole compensation,
will do the work and the structure u Out intended or offered for sale(Sec.7014,Business
and professions Code:The Contractor's License Law does BOB apply m an owner of Required Inspections
property who Wilds or improves thereon,and who dwssueh work himmlfor through his
Own employes,provided that such improvements an,not intended oroffered foriale.If.
hmild)cr the
aved ore orimprovementwldedi withinoneyear of cprove for
owner- \ f'y
builder will have dm burden of proving Nat W did not build or improve(or puRau of
sale.).
❑1,as owner of the property am exclusively contracting with licensed contractors toconst
woose, a it project(sec.o an Business and property
who
Code:)The Contractors nd
cense Law dors not apply je it owns of protons who seolds or improves thereon,and
whocontractsLa for such projects with a contractor(s)licensed pursuant to dm Conmectora (6117 1
0 1 am Law.
1 am exempt undo sec. .B&P C for this reazan 1
Owner Data 1
737WWORKER'S COMPENSATION DECLARATION "
I hereby affirm under penalty of perjury one Of the following declensions:
have and will maintain a Certificate,of Consent elf-insure for Worker's Compcn-
n,as provided for by Section 3]00 of the IsWr Code,for the performance of the
for which this permit is issued.
have and will maintain Workers Compensation Insurance,m required by Section
of thc Labor Codc,for the performance of tie work for which this a t is issued.
Wnrkc( ATrim}ddom IInsu ante,em ar and Policy cr. y r•fr(i f _ts's-¢) Policy No.: `
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(This section need not W completed if the permit is formic hundred dollars($100)
or las)
1 cerify dens in the perform C the, .,it f hich Nis permit a issued,I scall our
employ any person in any in bjem to NC WorkeK Compensation
Laws of California.Date
Applicant
NOTICE TO APPLICANT:If,ager making this Cerifcate of Exemption.you should
bccomc mace,to the Workers Compensation provisions of the la Wr Coda you no.
foMwith comply with such previsions or this permit shall W deemed remked,
z CONSTRUCTION LENDING AGENCY
'p.�-• I hereby affirm that them is a construction lending agency lot the performs z of
D: dte work for which this porton is issued(Sec.3097,Civ.C.)
lA Q Lenders Name
Isndetress
Add
U 1
IT,p I eerie Nat I have read this application and sate that and
su m information
ng is
0 F broader 1 agree m comply with all city and roomy ordinances and sum laws relating e
V move-gconmned construction,andfor by iospechudaertneses. siva of this city mentor upon the
aMvc(We) ed,rotors forimnify an it.,ho
F C
(We)ag e to mm,indemnify and hich harmless de City of against s against
i,iZliemora.judgmenu,"atimand efthes which may in anywyacrnm against said City
Aconmqucnceof Ne g STAN of this emit. v J
V z AP NT LAND STAND AN WILL COMPLY WITH ALL NON-POINT Issued by: Date
J
50 CE GUL S. ? ^�
�L/ Re-roofs
Signmurt of Appli nuConuactr Dam
HAZARD S MATERIALS DISCLOSURE Type of Roof
Will the Clicamrm Mu buildings.Chapter
mor handle ha�uusmamdal
az de0ned by 125 Cupertino Municipal Code.Chapmr 9.11,and the Health and safety
COIe.Seunitdon 23532(a)? All roofs shall be inspected prior to any roofing material being installed.
❑ �Nu
IWill Ne applicant or future building Occupant use equipment or dcvica which If a roof is installed without first obtaining an inspection,I agree to remove
t hazardous air contaminants as defined by the Bay Area Air Quality Management all new materials for inspection.
Diwict?
❑Yes ❑NU
I have mail the hanNous mamrials requirements uncer Chapter 6.95 of the Califor-
niaHealth 6SafetyCode,sections 25505,25533 and 25534.1 undemmnd that lithe Wilding
does nut curremly have a¢ren at it is my responsibility m notify the occupant of the
regyivme\n mnv bens Inner iousioncetor.eenificamnf Oceopanc. Signature of Applicant Date
`�� Z�^�� All roof coverings to be Class"B"or better
O cr tartar awho�a Date