05060034CITY OF CUPERTINO
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BUILDING DIVISION PERMIT
CONTRAGTORANFORMATION: -
BUILDING ADDRESS:
NOVO CONSTRUCTION
PERMIT NOO 5060034
OWNER'S NAME:
PERMIT L4UE DATE
NE:
SANITARY N0. CONTROL NO.
ARCHI=rENGINEER:
BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
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LICENSED CONTRACTORS DECLARATION
Job Description
1 hereby elBrm that 1 am Iicenacd under provisions of Chapter 9 (commencing
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Division 7of NC Business and Professions Code, endmyliccnsc is
withSectionand
in full ToftJe and clfea.
®lar ����®
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REPLACE COOLING TOWER
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�ppYtlA■y
Data v a"7
NEW ROOF LOCATION
ARCHITECTS DECLARATION
1 understand my plans shall he used as public records
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Liccnscd Pmfessiond
OWNER -BUILDER DECLARATION
I hereby .(Sere 1 fore the feemm�Co License taw for the
ancio on 1.. Brume Code: Any city or roomy
followingumesa (Snit ]comm Business and
improve, dcionli
re cnnomn, oldie Impmw, demolish, or repair any income
which requires a O
c,.Iso Pcrmiuo f Ic i signed nammem
prior m its issuance, also nt in t e she applicant tforhe Contractor's law (Chapmr9
(comm iscing wit pursuant in the ivioaof theeB and
Sq. Ft. Floor Area
T850
usi:tur
of DivisionProc
cixempth Section wit of Divi onrth exeend Professions Csale) or
gleed
Nat he u exempt therefore and Nc bats for dm alleged exemption. Any violation of
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APN Number
Occupancy Type
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Section 9031.5 by any applicant for a permit subjects she applicant W a civil pcnahy at
not mom Nan 0w hundred dollars ($500).
32633113.00
El 1, as owner of the property, Or my cmPloyma with wage a their sole compensation,
Required Inspections
will do the work. and to structure is not Intended or offered for sale (Sec. ]044. Business
and Professions Code: The Contractor's License Law does not apply w an owner of
pmpcny who builds or improves thereon, and who does suchworkhimself or Nmugh his
awn employees, provided Nat such improvements are not intended oroRered forsols. If.
however, Ne building or improvement is sold within one year of compkuon, the owner -
builder wit have the burden of proving Nal he did not build or improve for purpose of
ale J.
❑ 1, a owner of Use property, am exclusively con=ting with licensed comsacwrs to
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construct the project (Sec. 7014. Business and Professions Cade:) The Contractors Lv
Come law doe not apply to an owner of property who builds or impmveUs Ncrtpn, and
who conese s for such pmjcca with a convacmr(s) licamid pursuant to the Cartracto's
License law.
❑ 1 am exempt anchor Sec. . B h P e for this reason
Owner Dat
WORKER'S COMPENSATION DECLARATION
1 hereby aBhm under penalty of perjury one of the following declarations:
1 haw and will maintain a CeniOaa¢ of Consent to self-imum for Worker's Crimper -
as provided fm by Secuan 3700 of the labor Code. for the performmsx of the
work for which Nis permis is issued.
❑ 1 have and will maintain Workers Compcnsoion Insurance, as required by Section
39(0 of the labor Code, for Ne performance or the work for which this permit is issued.
My Work'�� ss Compensation Insurance carrier and Policy number art:
Carrier. Its-1'NhL7�T4'0C . Policy No.: I S2_0 _
CERTIFICATE OF EXEMPTION FROM WORKERS
COMPENSATION INSURANCE
(Tits section need not bceomplemd if the permit is foronc hundred dollars (SIB()
in less)
1 ceNfy Nat in the performance of the work for which this permit is issued. I shall not
employ anyrrion in any me minso as W become subject to NC Workeri eompenution
Laws of Calromia. Date
Applicant
NOTICE To APPLICANT: If, after making this CcniOcae of Exemption. you should
become subject to the Worker's Compensation previsions of to tabor Code, you must
rorthwith comply wit such provisions or this permit shall be deemed mwkcd.
CONSTRUCTION LENDING AGENCY
1 hereby affirm Nat chert is a coauucuon lending agency for the perfumomm or
Oc work fur which Nis From, is issued (See 3097. Ci, C.)
Lenders Namc
Lenders Address
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1 comfy Out 1 have read this application and slam Our she above information is
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COMCL 1 agree m comply with all city and county aNinantts and stale laws relating to
building construction, and hereby auNOoMrepreenutives of this city to enter upon the
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aMve.menuoned Progeny far inspection pts s
(We) agree m save, indcmmfy an p harmiaa the City of Cvpenin, against
liabilities. judgments, costs and expcn w ich may in any way acetic against Mid City
in can e
APPNT U �RSTAN AND WILL COMPLY WITH NO -POINT
Issued by: Date 7 6—
SO EREOU A�� 7��
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Re -roofs r ru
Type of Roof
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ighawrt ofApplic HAZARDOUS MATERIALS DISCLOSURE Dam
Will the applicant or future building occupant nam or handle hazardous material
as defined by the Cupertino Municipal Code. Chapter 9.12, and the Health and Safety
Code. Sccuon 25532(a)?
All roofs shall be inspected prior to an roofing material being installed.
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If a roof is installed without first obtaining an inspection, I agree to remove
Will the applicant or future building occupant tau cquipmentor device which
mit havardous air contaminants as dCTWcd by the Bay Area Air Quality Management
all new materials for inspection.
District?
❑ Yes t�'No
I haw mal Nehvardousmamrial quiremcnts under Chapmr6.95 ofthe Califon
nu Health L Safetycodc, Sections 25 .i55JJ am125574.1 undcrsland Our it Nc Wilding
does not cunen C it u my respoaibility o notify the eupanI Of the
require ntaw m6ahem ptiarWiauyeearlcerllBe:mmrfY
Signature of Applicant Date
> 6 5
All roof coverings to be Class "B" or better
Ow�m,
Or awhmirmd ago Date