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CITY OF CUPERTINO
BUILDING DIVISION PERMIT
CONTRACTOR INFORMATIQN "•
BU ILDING ADDRESS:
NOVO CONSTRUCTION
PERMR NO
05030110
OWNER'S NAME:
PERMIT ISSUE DATE
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SANITARY O. 11 C OL NO.
ARCHITECT/ENGINEER:
BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
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LICENSED CONTRACTOR'S DECLARATION
Job Description
1 hereby affirm Nat I am licensed under previsions of Chapter 9 (commencing
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with Section 70M, mf Division 3.f the Business and Pmf,sWors Code, and my license is
in full force and effect.
Lieenae Class Lie., �QI()aa
TI-INTERIOR/NEW T-BAR/WALL
HVAC/ELECTRIC
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TSDECL "N't
ARCHITECTS DECLARATION
I understand my plans shall W used as public records
30 -DAY TEMP PERMIT #05030222
Ldensed Professional
OWNER -BUILDER DECLARATION
1 hereby affirm Nos I am exempt from to Conunctor's License Law far the
fallowing reason. (Smdon nn I.S. Business and Pmfessinm Code: Any city or county
.,.I. which rtquia permit to construct, alter, improve. demolish, or repair any soneme
prior to its issuance, also require& the applicant for such permit to rile a signed statement
that he is licensed pursuant to the previsions of the Contractor's License Law( Chapter 9
Sq. Ft. Floor Area
Valuation
(commencing with Section 7") of Division J or the Business and Professimu Code) or
dot he is exempt donations and the Buis for the alleged! exemption. My violation of
AITN Number
Occupancy Type
Section 7031.5 by any applicant for apermit subjects the applicanuo a civil penalty of
not more than five hundred dollars (S5W).
❑ 1, u owner of the property, or my employees with wages as their sole comPenaadon,
32610065.00 -�
Required Inspections
will do the work. and the structure is not intended .,offered fmnale(Sec.J04f. Business
and Pmfeasinm Code: The Cones License law does mot apply a an owner of
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property who builds m improv, thereon. and who dmssuchwork himself or through his
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own employees, provided disk such improwmenu ma not intended or offered for rale. If,
how,vr. the Wilding or improvement is and within one year of completion, the owner.
builder will have she burden of proving that he did nm Wild or improve for purpose of
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sale.,.
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❑ L u owner of the property, am exclusively contracting with licensed contractors to
construct the project (Sec. 7W, Business and Profe[LORi Code:) The Connacmnf LI
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ce,e law dues not apply to an owner of property who Wilds or impmvu themon. and
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who contracts for such projects with a contractor(s) licensed pursuant to the COmn&atmel
r 1
License law.
❑ I am exempt under Sec. .B& P C for this reason
Owner Data
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WORKER'S COMPENSATION DECLARATION
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1 hereby aRnn under Peaty of perjury ore of tie following dcclararima:
ham and will mainuin a Certificate of Consent o self-insum for Worker's Compen.
n, as provided for by Section 37M of the labor Code, for the performance of the
work for which thio permit is issued.
❑ I hoe and will maintain Worker's Compensation Imsurana, as required by Suction
37W of the labor Code, for the performance of the work for which this permit is issued.
My Work Companadon Insurance comic, mid Policy numberam:
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tamer: epwol I C Tri'e'Y� I F G�
RnC— RCAPT! 0th OM WORKERS'
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COMPENSATION INSURANCE
(This section need Out he completed if 1W permit is foram hundred dollars (SIM)
or less)
I ttnify Nm in the performance of the work for which this Permit is issued. l shall not
employ any person in any manner so az m become subject to she WorkersCompensation
Laws of Califomia. Date
Applicant
NOTICE TO APPLICANT: If, after making this Certificate of Exemption, you should
become suhjca m the Worker's Compensation provisions of the Labor Code, you muss
forthwith comply with such Pmvbinru M Nis permit shalt W deemed revoked.
CONSTRUCTION LENDING AGENCY
'
I hereby off rm that is agency Ire she Performance of
sed(Sett.Constructionlending
' the work for which Nis permit u issued (Sec. J091, Civ. C.)
jLendr's Name
I<naera Address
j 1 certify that 1 have read this application and m e that the above infmmuiun is
' correct. l since to comply with all city and county ordinances and state laws missing to
building construction, and hereby aurhorme represenutises of this city to enter upon de,
ahovcmendanedrpn fori,pecdon innposes.
(Wc) agrraa�� m uk, indemnify andikccp harmless the City or Cupcttino against
which
j liabilities, judgmcdo, costs and expenses may in any way scenic &gains, "it City
in co,equcnce of thegmnting of this permit.
' APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON -POINT
Issued by:%V� Date
SOURCE REGULATIONS
1
Re -roofs
Type of Roof
O,
Sigmund oApplicmiXonliactotDate
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HAZARDOUS MATERIALS DISCLOSURE
Wild, learn,
defined ncMpmoor fuwnc building mcupmwom or handle M1arallom material
az Municipal Code. Chapter 9.11, and the Health and Safety
talc, Section 25533(a)7
❑Y, AN.
All roofs shall be inspected prior to any roofing material being installed.
If a roof is installed without first obtaining an inspection, I agree to remove
Will the applicant or future building Occupant use equipment or devices which
H WeardWs Or contaminants as defined by the Bay Ama Air Quality Management
all new materials for inspection.
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❑Yes
jhe
I have mail t.Nous mmcrialsmquimmcnuundcr Chapter 6M.Rhe Calif.,.
MA H,I"Safety CO&; ScWom 25505.3;5J3 and 25534.1urdersund tharifthe Wilding
does not currently 6&m a Writer. Nat it is my mspone hiliry W minty tie occupant of Jrc
req immcnW which must be et pnoriu isspm«mr&cenifi,W q`r aeppancy. _
Signature of Applicant Dale
L� I—y-os
All roof coverings to be Class "B" or better
Ownerbr authonmd agent/ Date