05030203 CITY OF CUPERTINO +'i+
BUILDING DIVISION PERMIT CONTRAGTORINFORMATIQN:
BUILDING ADDRESS: PERMIT NO.
NOVO CONSTRUCTION 05030203
10421 14 99 ANZA 91LIVID
OWNER'S NAME: PERMIT ISSUE DATE
ONE: SANITARY c OL NO.
ARCHITECDENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
0 0 0 0
X00 LICENSED CONTRACTOR'S DECLARATION Job Description
wC I hemby affirm that 1 am licerved under provisions of Chapter 9(Commencing P
iW with Scetion 7000)of Division 3 ofthe Business and Professions Code,and my license is
in full farce and even.
$pi Liccnmclav Llc.g TI--1ST FL. / REMOVE (E) GYP. BD CLGS
-'3 o.m cmr
raj ARCHITECTSConloontnDECLARATION T-BAR GLGS & FAUX COLS . INSTALL NEW SUSP . CLG
1 undersand my plans shall N used as public records
�aU
G Liccnicd Pnsfcssional
5 OWNER-BUILDER DECLARATION
.�n o 1 hereby maso .Ilbm Nm 11. exempt from Ne ContractorsoLicense Lew for the
_p o following mason.(Section WE1.5.Business and Nn.dein li Calc:Any city structure a'�m which mquima a permit 1.n cnrsuuct,alter,improve,xermitt, file
mash any swmum
F Z< prior w is issuance.p akdim to res the
ovisio antsof for such permit m Elmer Law
(Chapter
Nommecing it puution 7Ne of Division
of the Contractor's Lhcnmlaw(C ode)at Sq. F[. Floor Area Va1LtHtiOnooO
�t2-o (commis asgwith Section VOW)of Division)of the C,cd essantlmi.A.i Code)at
4
W�$ sal he u esempt tNmfrom and de breis for Ne allegrd exemption.Any violation of
Section]031.5 by any applicant for a permit su invent to applicant to a civil penalty of APN Number Occupancy T
not mn five thae hundred dollars(5500). P y YPe
❑I,ax owner of Ne property.or mY employees with wages v Heir sole compensation. 32633114 . 00
will do the work,and She swctum is not in arced or offered forsake,(Sec.7[ul Bu4mss
and Pmfeuimu Cox:The Condamine,License Law does not apply an am owner of Required Inspections
property who builds orimpraves demon,and who doessuch work himsel(ar through his
own employees,provided that such impmvemenu...I lateMW ar.Remd forsak.If.
however.on,building or improvement is sold within one year of mmplction,da. want-
builder will have she burden of proving that he did not build or improve for purpose of
salo.). — ..
❑h as mane,of Ne property,am ucbuively cants tilting with licensed contractors to
construct the project(Sec.7014,Business and Profestimu Cade:)The Conuacmr's Li-
enors,law docs not apply to an owner of property,who Wilds or improves Nenan,and.
who mntncu for such projects with a conuacmr0)licensed pursuant to the Contractors T/
1am law.
0
lam esempt under Sea ,BBPC for this mason
Owner Data
WORKER'S COMPENSATION DECLARATION
I hereby affirm under penalty of perjury one of to following xdarations: U 1 J
❑I have and will maintain a CcW ficatc ofConsem in self-insum for Worker's Compton-
. ration,u pravidcd for by Smdon 37M of the Labor Code.far the performance of use
work(or which air permit is issued.
1 have and will maintain Workers Compensation Insurance,in required by Section
3]00 of the Labor Cade,for Ne,performanm of ae work for which Nis permit is issued.
My Workers Compcmauon Insurance carrier and Policy number am:
Cartier: Policy No.:
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(Thin section need not he completed if tN permit is foronc hundred dollars(glo)
or less.)
I cenify that in the performance of the work for which this permit is issued.I altall not
employ by person in any manner m as as become subject to Ne Workms'CompermNon
Laws of California.Dam
Applicant
NOTICE TO APPLICANT:If.after making this Cenifcam of Exemption,you should
become subject in the Worker's Compensation previsions of the labor CMC,you most
O forthwith comply with such provisions or this permit shall be deemed mvnkcd.
E^ CONSTRUCTION LENDING AGENCY
[—i Ihemhy affirm that tort is a construction lending agency for the performance of
(Y. the work for which this permit is issued(Sec.3097.Civ.C.)
LA Lenders Name
=Z Lenders Address
U p 1 cenify that I have mad this application and sum that the above information is
U, f" coved.1 agree to Comply with all city and county Ordinances and sonic laws mlating m
0 U Wilding construction,and hereby submin mismami natives of this city to enter upon dm
Y'LT•1 aove-menioned property for impection purposes.
(We)agora to save,indemnify and keep harmless Ne City of Cupertino against
Hliabilities,judgments.costs and espertms which may in any way accmc against said City
U in consequence of ate granting of this permit.
^' APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT Issued by: Date
SOURCE REGULATIONS.
Re-roofs
HAZARDOUS
Signsure of ApplicaDam
HAZARDODO US MATERIALS DISCLOSURE Type of Roof
Will the applicant or(Muni building Occupant name of handle Health a d Safety u defined by the Cupertino Municipal Cox.Chapter 9.12.and the Health and Safety '
Cook.Section 15532(.)? All roofs shall be inspected nor to any roofing material being installed.0 N
Will the applicant or future building Occupant use equipmem or devises which If a roof is installed without first obtaining an inspection,I agree to remove
emit hazartlnus air conuminans es de0ncd by to Bay Arta Air Quiity Managemem all new materials for inspection.
District?
❑Yes 0 N
I have mad the hazardous materials requimroors under Chapter 6.95 of the Coli for
ria Hcslth k Safety Cox,Sado.15505.35533 end 15534.1 unM.d Nm ifNe Nitding
does not currently have a tenant,Nat it u my responsibility m modify the arupsnt of the
mquiremems which mus N met poor to issuance o(a Certificate of Occupancy. Signature Of Applicant Date
Owner or sothod.ed agent Date All roof coverings to be Class"B"or better