05030013 (NER'SNAME
F CUPERTINO ,^c ria -
BUILDING Dlvlslory PERNIITCONTRACTOR`INF,ORMATION '
DDRESS: PERMIT NQ.5 0 3 0 013
ME: PERMIT ISSUER DATE
T FOOD SANITARY NO. CONTROL N0.
/ENGINEER: BUILDING PERMITINFO
PLUMB MECH
LICENSED CONTRACTOR'S DECLARATION
by afrrm Nal l am liwnxd under provisions of Chap¢r 9(commcncing Job Description
")of Division3ofihe Businessand Proremonn Code,and mylicense is ��n 7
;„ in full[one and effect. TI--BUILD PARTITION WALL/'UP,GRADE RESTRM/
p la Z License Class Lic.is
zgn Dam Conuaemr UPGRADE A/C
�� AR Call tic TS DECLARATION
S.. I understand my plans shall be need az public records
;tali'0U 1
Licensed Professional �� 9
+03 OWNER-BUILDERexemptDECLARATION ln��
.0 0 1 hobo afrrm that 1 1. exempt from Ne Cosions Cor License Law for the
p O following moon.(Section RATS,Business and improve,
Professions ts,of Any city or county
y m which requires a e.Mo re cnnswct,alter,improve,h Permit t fi repair any swment
pri«miuiensedprsu requires tbevisionofcant for wchpermrpofile a ccose,aw(Cha mem J)tr^ Valdl�
that kis licensed pursuant 7000)of Divionnftk CommnessadPof Law(Chapter Sq. FI. FloorArea �uU { 900
w�S (eat he
(commencing erefournand f basis for
them Business and Profession Gme)w C`
s 3-
that he u exempt Nertlom and Ne bazu for the alleged exemption.Any violation of \\
Section 7031.3 by My applicator for•permit subjects the applicant to a civil penalty of APN Number Occupancy Type
not mom than BK hundred deltara 35917001 . 00
C]1,az owner of the popcny.a my employee with wage u their sole compensstion,
will do the work and sup Nucmre is not intended or offered fertile(Sce.7044,Business Required Inspections
and Professions Code:The Conuadon of,License Law donal apply m an oewner of q P
property who Wilds or impmws thereon,and who doessuch wort himselfor through his
own employces.provided Nat such improvements are not immmdW or offered for We.If.
however,the building or improvement is sold within one year of completion,the owner-
builder will ban the torden of proving that he did our Wim or improve for purpose of
sale.).
1,as owner of this property.am eaclusively contracting with licensed contractors to
colavuct the project(Sec.7644,Business and Pmfessiam Code:)The Contrumri Li.
certse Law duet not apply as in owner Of property who Wilds Of improver themM,and
who contracts for such projects with aeonuacmr(s)licensed pursuant to the Comracmrs
License law.
❑1 arg4aeraps «Sec. B&P C for this season
nor Dam
WORKER'S COMP1ra 14 DECLARATION "
1 hereby affirm under pcnaltY ofycq ry one of Ne following dielantimu:
haw and will maintain a CeniGnr,of Consent to self intim for WorkeraCompen-
n,az provided for by Section 37W of the Labor Codc,for the performance of the
for which this permit is issued.
7017.,l
have and will maintain Worker's Compensation Insurance,as required by Section
of the labor Cock,for tW performance of the work for which this permit is issued.
Workers Compensation Insurance came,and Policy work,arc:
er. Policy No.: _
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(This section need not kcomplc¢d if the permit is for one hundred dollars(SIM)
ormix)
I ecru(,,that in that performance of the work for which Nit permit is issued.I shall not
employ any person in any manneru as to become sobjnno the WorkersCompcvadon
Laws of California.Dam
Applicant
NOTICE TO APPLICANT:If,afar making this Cenificam of Exemption,you Mould
become subject in the Worker's Comp«umion previsions of the LaWr Code,you must
0 O forthwith comply with such provisions or this permit shall be deemed revoked.
Z`w CONSTRUCTION LENDING AGENCY
[-+ I hereby affirm that them is a construction lending ageucY for the performance of
C the work for which this permit is issued(Sec.3097,Ci,C.)
4 Q Lenders Nana
Umlm,.Address
V Q 1 certify Net 1 ban mad this application and star,that Ne about information is
U. F commit.)agree m comply with all city and county oNimneetand sum laws bilitifirl,to
0V p
building emomoVion,and hereby authorise represenudim of this city m enter upon the
L[1 Mum-mentionedroperty for inspection purposes.
f-'C. (We)agree to save,indemnify and keep harmless 00)City of Capertinr against
rn liabilities,judgments.costs and expenses which may in any way ammo,against said City
V Z in consequence of the granting of this permit. _
^" APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT Issued by: Date-3/--7
SOURSE.REO NS.
3-1_6_`L Re-roofs
Signature ofA plicaMContraclor Dam .
HAZARDDUSMAT 1 ,$DISCLOSURE Type of Roof
Will ON applicant or future Willing pant.nore sur handichvardmusmaarial
dcfinetl Cupertino Municipal Code.Chaper 9.12,and On Health and Safety
e, MYes by 0m 25512(x)? 1alfNr All roofs shall be inspected prior to any roofing material being installed.
�Ycs
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
Id%(
hazardous air contaminants u Ucrnmd by the Bay Area Air Quality Management all new materials for inspection.
ire?
❑Yeses
1 have mail the hvandousmamrialsmquirements under Chapar 6.95 of the Califor-
afety Cede.Sections 255)5,15533 and 25534.1 undemund that if the Wilding
ntly have a enam,thatit is my responsibility m firmly the mcupam Of the
whihmu kmet to ad ecofacerdrntcoracupanmy. Signature of Applicant Date
�j_ —0 S
OwnerauthomN acm Dae All roof coverings to be Class"B" or better