05020107CITY OF CUPERTINO
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BUILDING DIVISION PPRMIT
' C50NTRAC-TTOR4NEORMATION,
BUILDING ADDRESS:
NOVO CONSTRUCTION
PERMIT N 65020107
OWNER'S NAME:
PERMIT ISSUE DATE
APPLE
E:
SANITARY N0. CONTROL NO.
(650)701-1500
ARCHDECT(ENGINEER:
BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
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LICENSED CONTRACTOR'S DECLARATION
Job Description
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I hereby affirm that I am licensed under prow ons or Chapter 9 (commencing
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with Section 7") of Division 3 of the Business and Professions Code, and my license is
mInti roreeand erre d%%162Zy
REVISION --IN HOUSE USE ONLY
License Class Lk. x
Date cartracmr .ciGcuO
NO NEW PERMIT ISSUED/ ORIG. #05010056
ARCHf1ECTSDECLA ATIOON
1 undersunJ my plants shall be used az public ¢cards
Licensed Pisfessioenl
OWNER -BUILDER DECLARATION
I hereby affirm that 1 am exempt from the ConOactars License Law for the
following mason. (Section 7031.5. Business and Professions Cade: Any city or County
which requires a permit to Construct. he, improve, demolish, m repair any structure
prior in its issuance, also requires the applicant for such permit to file a signed summem
that he isliiccnmdpursuamtothe previsions ofineComractoraLicense Law Curer 9
Sq. Ft. Floor Area
Valuation $0
(commencing with Section 7000) of Division 3 of the Business and Professiont Code) or
that he is exempt therefrom and d¢ basis for the alleged caemption. Any violation of
APN Number
Occupancy T
P Y YPe
Section 7031.5 by any Applicant for a permit subjects Bin applicanuo a civil penalty of
not mole than firs hundred dollars (SSW).
32633113'00
01,azownu of the property,«my cmployceswim wagesaztheir sale compensation,
Required Inspections
will do die work and the swcwm is not intended oro@red forsale (Sec. 7044, Business
and Perfessians Code: The C.A...License Law dors not apply As an owner of
property who builds or improves memon, and who d«asuch work himself or through his
Own employees, provided that such improvements are not intended oraRemd forsale. If,
however, the building or improvement is sold within one year of completion, the owner -
builder will have the burden of proving that he did not build or improve for purpose of
salt.).
1, As Owner of Be peoparlY am exclusively contracting with licensed tonaatu rs to
construct the project (Sec. 7044. Business and Professions Cade:) The Contractor'. Li.
cense law dots not apply to an owner or property who builds or improrss thereon, and
who contracts for such projects with a contracmr(s) licensed pursuant to the Conmemre
Lkcnse Law.
0 1 ore exempt ..on, Sec. B k P C for this mazon
war Dare
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WORKER'S COMPENSATION DECLARATION
I hereby affirm under pmahy or perjury iso of the following declarations:
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maintain a Certificate of Cameno seir-mauve for WarkcrCarrier-
1 haw and will mu
Ano n, as pmvided for by Section 3700 of On labor Code, for the performance of the
work for which this permit is issued.
❑ 1 have and will maintain Worlmes Compensation Insurance, az required by Section
3700 of me labor Code. for me Performance of me work for which this permit is issued.
My Workcri Compensation Insurance carrier and Policy number am 4/
Carrier. ,;i✓.n• .eirFr✓..r' Polity No.: ZTZ�y�O/
CERTIFICA OF EKEMPGON FROM WORKERS'
COMPENSATION INSURANCE
(This section ocd not be completed if the permit is (more hundred dollars (x100)
or less.)
I ceni(y dint in the performance of Cot work for which this permit is issued, I shall not
employ any person in any manor an az to become subject to the Workcri Ca oransation
laws of California. Date
Applicant
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NOTICE TO APPLICANT: If, after making this Certificate of Exemption, you should
Wecome subject to me Worker'. Camonsmian provisions of me Labor Code, you must
forthwith Co.,), with such pr..isi«u or this permit shall be deemed invoked.
CONSTRUCTION LENDING AGENCY
1 hemhy alarm that roue is a conssruelien lending agency, fee the fardmmana of
die work for which this permit u issued (Sec. 3097, Civ. C.)
Le Mmes Name
Ummes Address
1 cenify that 1 have rend this application and sum mat the about information is
and County ordinances
to es
miming 1 agree to Comply with All city and county mJinmrm and Cute laws relating to
City
honer
/
building construction, mid city upon the
on, and hereby a One
ahove-mentioned property for Inspection purlwses.
(we) agree m save, indemnify and keep harmless me City of Cupertino against
liabilities,judgmen¢ costs and expenses which mayin anyway accrue Mitimusaid City
in consequence of the granting of this permit.
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APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON -POINT
/'y
Issued by: Date r f
SOURC ULATIONS.
J)y
4,
Re -roofs
Type of Roof
—�: ` — y� S
Signature OfAI,pilicamuCcruactor Date
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant Lir future building occupant store or handle haurdous mamrial
az defined by the Cupertino Municipal Code. Chapter 9.12. and the Health and Safety
,Wide. tli n25532(x7❑N
All roofs shall be inspected
nor to an roofing material being installed.Yea
a
If a roof is installed without first obtaining an inspection, I agree to remove
Will the applicart or (.Lure buildingucwhich
t herardons air contaminants az defined by me Bay Area Air Quality M .... Comm
all new materials for inspection.
District?
❑Ycs ON.
1 have mail the havmdous mawrialsreyuirements under Chapterb.95 of the Califor.
a
M. Health& Ssficy Cade, Sccmms 25505.25533 it 25534.1 understand mmifine building
dues not currently have a tenant, that it is my responsibility m nobly the occupant of the
rtyutmm lis Ct be met prior to issuance of a Certificate of Occupancy.
Signature of Applicant Date
�s
All roof coverings to be Class "B" or better
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.m«au,h.d cd agent"' Cott