05020126 CI TY OF CUPERTINO
BUILDING DIVISION PERMIT v�,ONTRACT�ORLNFRMATIQN
BUIL DING ADDRESS: ASSOCIATED CONTRACTORS COR P""MITN`05020126
NER'S NAME: PERMIT ISSUE DATE
TRE
,,ONE: SANITARY NO. CONTROL NO.
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ARCHITEC TENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
0 0 0 0
y_Op LICENSED CONTRACTOR'S DECLARATION
to FF 1 hereby affirm that 1 am licensed under previsions of Chapter 9(commencing Job Description
Ico with Section 7WU)ofowision 3.fMC Businoa and Professore Code.and my license is
n« in full force and effort,
,iAE License tic.• d o� TI--2 OFFICES/ERECT 1 WALL @ LOBBY
fo Date
—y�ComrxC A N OeJy
ARCHITECTS DECLARATION
1 undersand my plans shall W used as public records /
,6u �!
Licensed encs iITel
OWNER-BUILDER DECLARATION
Q0 1 hereby affirm thea 11. exempt from the Contractors License Law far my G
Q O following masa n.Permit
t 7 construct,
Businessmpr and improve.
detium Code:Any city orsomeone,requiresnn
F_< prior in its issuance,also requires the applicant for such Permit o file a signed sutemcnt
iso thn W is licensed parmantm Me provisiota or Me Common's U..Law(chapter 9 Sq.Ft. Floor Area Valuation
��$ (commencing with Section 7")of Division 3 of Me Business and Prefaxiom Crtdo)of
that he is exempt Ihciefrom and the basis for the alleged exemption.Any violation of
Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of 3 20341I9tVi betO 0 Occupancy Type
not mom Nan rive hundred doll..($M
❑I.ra dvabr of the pmpxrt,ormy employees with wages as dmir role Compensation,
will do the work.and Ne structure is not intended or offered for age(Sec. Business Re uired Ins ections
and Profession,Code:The Contracture License law dam not apply to an owner of q p
property who Wilds or improves domon,and whodoessuch workhimadfor through his
awn employees.provided Nat such impvemenu sm not intended oroffered fmsak.if.
however,the Wilding or improvement is sold within one year of Compleuon.Ne owner.
builder will have Ne burden of proving that W did not Wild or improve for purpose of
sale.).
❑1,as Owner of the property,am exclusively contracting with licensed comaacto.tO
Construct the project(Sec.7(o44,Business and Professions Code:)The Contractor's Li.
cense law Gots not apply to an owner Of property who Wilds or improves themmn,and
who cantocts for such projects with a cont..or(s)licensed pursuant to the Contractors
License raw.
❑l am exempt under Sec. ,B&PC for this mason
ter
Data
WORKER'S COMPENSATION DECLARATION
1 hereby affirm under penalty of perjuty one of the following declarations:
1 have and will maintain a Certificate of Consent to self-insure for Workers ComPem
section,as provided fin by Sccrien 3700 of the IaWr Code,for the performance of the
work for which this Permit is issued.
El I have and will maintain Worker's Compensation Insurance,as required by Section
37M of the Latin Code,for the performance of Ne work for which this permit u issued.
My Workers Compabation Insurance carrier uWPu[icy number an'
Cartier, uvi�
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(This section need not W completed if the permit Is for one hundred dollars(SIM)
or less.)
1 certify Nat in Ne performance of on,work for which this Permit is issued,I shall not
employ any person in any manner so as m become Object 10 the Workers Compensation
Laws of California.Date
Applicant
NOTICE TO APPLICANT:If,after making Nu Certificate of Exemption,you should
become sabjce,in the Worker's Compensation previsions of Me Labor Cade.you must
wJO foMwith comply with such provisions or Nis permit shall W deemrevoked
.z
re .
Z PMCONSTRUCTION LENDING AGENCY
I hereby affirm Nat them is a construction lending agency for the Perrurmance of
0Y Ne work for which Nis permit is issued(Sec.3097,Civ.C.)
DI Q Lender's Name
= ,Z Undeis Address
V Q 1 Certify that I have rad Nis ap,IMM..and ser.that the show Ofoanatiun u
ti.E^ Cromer.I agree to comply with all city and county Ordinances and sate laws relating to
OU building Construction,and hereby authodm reprcxnutims of this city to collar upon the
H� abuse-(We)agreeil
In s ray for inspection
mnify an dee,hs.
O.
(We)agree to Cast,indemnify and which
harmless w City scenic
Cupertino against 2 0
fg
Liabilities,jnce of the
Costsandof thisexpenseswhtch mayin anyway eccmc againstmid City L/� V
C.3 nZ. Aconsequence ofthc Roaming of this permit.
APPLICANT UNDERS L COMPLY WITH ALL NON-POINT Issued by: Date
SOURCEREG S.
(2 ---
/Z ZA'a" Re-roofs
Sigmaure of Applieut uaemr Date
A ARODUS MATERIALS DISCLOSURE Type of Roof
Will de applicant or future Wilding uccupamtstore or handle hwardous material
as defined by Ne Cupertino Municipal Code.Chapter 9.12,and the Health and Safety
ode.secYes tion 25532(a)7a)7 All roofs shall be inspected prior to any roofing material being installed.
❑ 'O'tJu
Will Me applicant or future building occupant sou equipment or devices which If a roof is installed without first obtaining an inspection,I agree to remove
mi:hazardous air conuminams as defined by the Bay Arta Air Quality Management all new materials for inspection.
District?
❑Yes NO
I have mm3 the Wand")
materialsmquimmena under Chapmr6.95 of the Califo>
MHealth&Safety Code,Sections 25505.25533 and 25534.1 undcrsund tharif thc building
docs not Cuaendy haw a notion,that it u my responsibiltty tu norh y the occupant of de
myuiremc merpdorwiaaanetar.certifi mor tapaney. Signa[ureofApplican[ Date
Oh All roof coverings to be Class"B"or better
Gwneruraut agent Dau