05030086 CITY OF CUPERTINO "s' `5�7ik
BUILDING DIVISION PRRMIT CONTRACTOR INFORMATION .
BUILDING ADDRESS: ASSOCIATED CONTRACTORS COR PERMITNo05030086
WNER'S NAME: PERMIT ISSUE DAIS
ONE: SANITARY N0. CONTROL N0.
CHTTECDENGTNEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
°00 LICENSED CONTRACTOR'S DECLARATION
I hereby affirm that I am licensed under provisions of Chapter 9(commencing Job Description
with Section 70(10)of Division 3 of the Business and Profession.,Code,and my license is
^OH infullforteandcffat. a Lie.., 70IZf?%4;
REVISION- -IN HOUSE USE ONLY
5 z Li«nae❑az� - iT� p�
�Fp Dam 'j COmracmr A550r'ri F11 lNaTi VI3t OrvL NEW PERMIT ISSUED/ORIG. #05020126
cul ARCHr1ECT5 DECLARATION
s 7 I understand my plans shall he used as public records
�pU
C N Licensed Professional
to I OWNER-BUILDER DECLARATION
.� y 1 hereby affirm that I am exempt from the Contractor's License Law for the
p O following reason.(Section 70211.5.Business and Pmf viuos Cak:Any city or county
which requires a permit to construct,alter,improve,demolish.at repair any structure
Fib prior m its issuance.also requires the applicant for such Permit to file a signed stammem
Y O that he is licensed p.ouanuotheProvisions nfthe Conmmur'sLianseLaw chapter,9 Sq.Ft.Floor Area Valuation $O
m€e� (commencing with Section 7")of Division 3 of the Business and Professions Cock)or
— that W is exempt therefrom and Ore basis for the alleged nemption.Any violation of r
Section 7031.5 by any applicam for a pc.I,s.bjccts the applicant to a civil penalty of APNNumber Occupancy Type
m
not more an five hundred Misr,($sol). — Pane Y YP
El I,az owner of the property,v my employee with wages as their sole compenuuon. 32634071 . 00
will do the work.and theswcmm is nor intnWed ser nRertA(.,.Me(Sec.7(X4,Business Required Iaction
and Profesiom Cache:The CanYi Licence rs m e ns law dooat apply an owner of q P s P`
Ownproperty doye ,providdsm ed that suchimon.andwhodcessneh work himsclforNrough his V
ownamploybuilding or
Natsuchimprovementsin not intended mOethm.ffercul for owhaL
however,the building u improvement is sold within one year of completion,Ne owner-
builder will have the burden of proving dot he did not Wild or improve for purpose of
salt.).
❑1,as Owner of one property,am exclusively contracting with licensed contractors to
connect thc projcm(Sec.7044.Business and Professions COdc:)The Conuacwr's Li.
ceruse law don not apply r'0 an owner of property who Wilds or improve thereon,and.
who contracts for such projects with a contractor(s)licensed pursuant m the Contractor's
License law.
❑I am exempt under Soc ,B&P C for this reazon
ner Date
WORKER'S COMPENSATION DECLARATION "
1 hereby affirm under penalty of prduty one Or Ne following declarations:
have and will maintain a Ccaiucate of Consent o selLinsum for WorkersCumpcn-
.az provided for by Section 3700 of the IOW,Code,For the penmmanee of the
it for which this permit is issued.
1 have and will mainuin Worker's CompenUarm baboons,n required by Section
3700 of the labor Code,for the performance or Ne work for which this permit is issued
My Worker's Campensauon Insurance prierd Policy ntunkran,
Garner. UV15 l]yN�i 2.�APPblicy No.:
CERTIFlCATE OF E%EMMON MOM WO KERS
COMPENSATION INSURANCE
(Ibisseetioo need ret W eanplemJ if tW Permit is for one hundrtA dollars($100)
or in.)
I certify that in thc performance of the work for which this Permit is issued.1 shall not
employ any person in any mummer so as m become subject 10 the Workers'Compenad on
Laws of California.Dam
Applicant
NOTICE TO APPLICANT:If,after making this CeniGcam of Exemption,you should
become subject ro the Worker's Compensation provision,of that labor Code,you mum
.,7, forthwith comply with such Provisions or this Permit shall W deemed Cowled.
z'O CONSfRUC'HON LENDING AGENCY
'r. ► Thereby affirm that One is a connection lending agency for the Performance of
lL' the work for which this permit is Wood(Sec.3099,Civ.C.)
D]Q Iandces Name
72 Landers Address
U Q I unify that I have mad this application and sum that the shout information is
Iy PCmmcL I agree to comply with all city and county ordinances and sum laws relating m
C)C.7building construction,and hereby authorize represemmivn of this city to enter upon the
Ln shove-mentioned Property for inaNcuon purposes.
(•' gy (We)agree m sane.indemnify+rad keep harmless the City of Cupertino against
y Iiabiliux,judgments.costs and expense which may in any way same against said City
U in emuccuencc Or the granting Of this permit.
^ APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT Issued by: Date
SOURC � I
-� 13 /o JF Re-roofs
Signmtirc of ppi UCOnmmor Dam
HAZARDOUS MATERIALS DISCLOSURE Type of Roof
Will the applicant or form building occupant mom or handle havudous material
160��na,
lved by the Cupertino Municipal Code Chapter 9.12,and the Heahh and Salary
. 0
Section 25532(a)? All roofs shall be inspected prior to any roofing material being installed.
Yes �Nu
If a roof is installed without first obtaining an inspection,I agree to remove
Will the applicant or forte building ottupam use equipment or Jcviccs which g
hazardous air contaminants as defined by t e Bay Area Air Quality Management all new materials for inspection.
rO
ClYes �No
I have mad the hvaNtms materials requirements under Chapter 6.95 of the Califon
ealth&SafctyCodc.Section 25515,25533 and 2x534.l undersand that i(Ne Wilding
not currently how a tenant mat it is my responihility m andfy the occupant of the
111eOdmeC3'cfj,4'c-pansySignature of Applicant Date
or atoWnv J erd / // Dam All roof coverings to be Class"B"or better