05030205 CITY OF CUPERTINOt.
BUILDING DIVISION PE MIT CONTit'A,CT('►, R INFORION'
B UILDING ADDRESS: HOLLANDER SMITH CONSTRUCTI PERMIT NO. 5030205
WNEWS NAME: PERhUT ISSUE DATE
E_ SANITARY O. 1 OL NO.
ARCHITECT/ENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
coo LICENSED CONTRACTOR'S DECLARATION Job Description
w❑ 1 hereby affirm that 1 am licensed under provisions of Chapter 9(commencing
�iW with Section IWO).(Division 3ofthc Business and Profcuions Colke.nd my license is
'n<a in full fora and effect
3'q_ License Ctaz. Lie,a TI--INTER. REMODEL ('NO STRUCTURAL)
��w Dore C.mrsntor 5 TELLER COUNTERS/3 OFFICES/l ATM/NIGHT DEPOSIT
j ARCHITECTS DECLARATION
� I undersand my plans shall M used u public aenrtls
JyU
G Liccnmd Professional /
S OWNER-BUILDER DECLARATION 6
I herehy arm Um I am exempt Dam the Comm
raOrs License law for the
p o fffollowing mason Permit
t consumer,
aboI, arid Pmfessiuu Calc:AnY city nr County
x m� which requires a Permit m cnnswet,alien improve,demolish,Or repair any structure
m�'^
poor to its Issuance.also Arimms the applicant forsuch Permit to rile asignedsutemcnl
that he is licensed Pursuanuehc provisions of the Committal's License Law(Chapter 9 Sq.Ft.Floor Area
¢tea (commencing with Section'!WB)ofDivision 3ofthe Business and Professions ende)or L X000
i�§ that he is exempt therefrom and frothe buis for the alleged camption.Any violation of
Section 7031.5 by any applicant for a Permit subjects the applicant to a civil penalty of APN Number Occupancy Type
not more than fin hundred dollars($500).
❑ 1.as owner of the pospon,,or my employees with wages aa their MIC compatoomfort. 35917023 . 00
will do the work,and din suumum is not intended or offered for sale(See told,Business Required Inspections
ae nsnd Professions Cade:The Contractor's License Law does not apply to an owner of 9 P
property who builds or improves thereon,and who does such work himself or through his
own employees,provided that such improvements are not intended or offered for sale.if.
however,the building or improvement is sold within One year of complcuon,the owncr-
builder will have the burden of proving thus he did not build or improve for purpose of
sale.).
❑h as Owner of the property,am exclusively contracting with licensed anuamors to
construct Be,project(See.1061.Business and Pofasions Code)The Comment's Li-
cense Law does not apply to an owner Of property who builds or improves themon,and
who contracts for such projects with a comracmr(s)licensed pursuant to the COnuaetors
LKenseLs .
❑ I am exempt under sec. .B k P C for this reason
1C333700
ner Data
WORKER'S COMPENSATION DECLARATION
I hereby affirm under pstraty Of perjury ane Of the following declamtiona,
I have and will maintain a Certificate of Consent m self-insure for Workers Compcn-
i.n,az provided for by Section 31W of the labor Code,for the performance of thus
rk for which this permit is issued.
I have and will maintain Worker's Compensation Insurance,u required by Section
of she lahur Code,for the Performance of the work for which his permit is issued,
y Workers Compensation Insumnec carrier and Policy number am:
rrier. Policy No.:
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(Thu section need not be completed ifde permit is fortune hunU dnitars(SIM)
A,less.)
1 curtly the,in the pcofiron oo of to work for which this Pcorru is issued,l shall nm
employ any person in my manrtef so az at become subject o he Workers Compensation .
laws of Catif nnia.Date
Applicant
NOTICE TO APPLICANT:If,after making this Certificate of Exemption,you should
become suhjcn On the Worker's Compensation provisions of the Latter Code,you must
.JO forthwith comply wish such provisions or this perm itthall be rumored revoked.
Z CONSTRUCTION LENDING AGENCY
sr� Ihcmby affirm that there is a construction lending agency ler the Performance of
(3' 7 the work for which this Permit is issued(Sec.3092.Ch,C.)
OW.Q tenders Name
0.rl Lcndcr's Address
U C) L certify that 1 have read this application and state that the above information is
iy P Correct.I agree to Comply with all city and county ordinances and sum laws relating to
pU building construction.and hereby auhome representatives of Los City to Cmv upon the
Y' W above-memionnd Property for trained..ptumoses.
f~ gy (We)agree to save,indemnify and keep harmless Lee City of Cupertino against
V z
liabilities,judgments,costs and expenses which may in any way accrue against said City
in
of the
^
APPLICANT UNDERSTANDSraining Of tAND WILL COMPLY WITH ALL NON-POINT Issued by: Date
SOURCE REGULATIONS.
Re-roofs
Signazurc of APPlicaR Date
HAZARDOUS
US MATE RIALS DISCLOSURE Type of Roof
Will thus applicant or fMuni building occupant r9.1 or handle ha�ous dSafrmaterial
az tlefined by the Cupertino Municipal Code Chapter 9.12.and the Health and Safety
We.section 25532(.)2 All roofs shall be inspected prior to any roofing material being installed.
❑Yes ❑No
Will thea applicant or future building.cert ant use equipment or devices which If a roof is installed without first obtaining an inspection, I agree to remove
nn s v a Air n
mit harardnas air contaminants az defined by Uc Bay Area Air Quality Managtmcm all new materials for inspection.
iatric'?
❑Yes 0 N
1 have read she mormlousmaterials requirements under Chap er 6.95 of dtc Califor-
iaHealthGsafetyCock,Sccu..25505.25533 and 25531.Iundermod that ifBc building
IA
oes no,Currently have a tan
ent,thus itis Any ronsibility m notify the occupant of of the
quirementswhich must inme(prior toissuance ofaCCniriamOfOccupxrcy
y Signature of Applicant Dale
Owner or aah.ri.d.,,^I Date All roof coverings to be Class "B" or better