04120011 CITY OF CUPERTINO •�' -
BUILDING DIVISIONPERMIT �CONTRACTOR�INFORMATION
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BUILDINGADDRESS: - PERMITNO04 12 0 0 11
10564 DE ANZ
^wNER'S NAME: PERMIT ISSUE DATE
BYER PROPERTIES
NE: SANITARY NO. CONTROL NO.
ARCHITEC iENGINEER: - BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
0 � 0
Lop LICENSED CONTRACTOR'S DECLARATION IobDescri [ion '
>: C 1 hereby affirm Net 1 am licensed under previsions of Chapter 9(Commencing p
-Z Uw "iN Sectimn 701111)of Division 3mf Jm Bonn.and Prufossium Code.and my license is -
in full Foxe and Affect. T I
p 12 i License Class Lic.N -
n F p Dam Contractor
ARCHITECTS DECLARATION
k< 1 understand my plans shall he used As public records
DyU
;oG Licensed Pmfcssinnal
3 OWNER-BUILDER m the Commences
E n o ON
1 hereby.ca .(firm she]1 1. exempt from Nc Cmnsxctmo :License Law for the
K_SO fullravwhiching.i..A oarritt ]Illsu Bminusand Pmfdemoli Code:Any cityorcounty
m io which rots iss a a e,Also de consumer,the alms impmw,demolish.t fie a sig any swcum
Fiy priarmits issuance.also myuir.s the applicam for such Permit filcaaigned summcm
< that he is licensed pursued m the pmvisiom of the Contracmr's Limnse Law(chapter 9 Sq.Ft. Floor Area _ Valuation
wG (commencing with Section 7flfll)of Division 3 of the Business and Prmfessimna CnJe)ur
i Nat he u exempt thcmfmm and the Ionia for the allegcd exemption.Any violation Of
Section 7071.5 by any applicant for a permit subjects the applicant to a civil penalty of gtO 0 Occupancy Type
not mom On five hundred dollar(SSW).
❑I.As ownerof the pmpeny.or employee with wages As their sol.compaiauon, _
will do On tush,and Nestrucsum is not intended mrmfferad fn...le(See.7044,Business
Add Pmressions Code:The Conusmr'n Lice.law does not appy in an Come,of - Required Inspections -• .
pmpeny who builds or improves tlencon,and whodousuch work himself or through his
own employees,provided Nat such improvements art not intended oroBarW foreale.If.
however.Ne Wilding or improvement is sold within one year of completion.the owner-
W ildcr will have she Wrdcn of proving that be did nos Wild Or improve for purpose of
ale.).
Y1,ss owner of the property,am exclusively contracting with licensed cuntracmrs to
mtstxct the prejecs(Sac.7044,Business and Profession Cade:)The Conu ecuer's U.
cede law docs not apply to an Owner of property who builds or imprem thereon,and. U �f/j`. /,•,'
who contracts for such projects with a cominceor(s)licensed pursuant to the ContnnoYs
License Law. "! r /
p 1son exempt and Sc. .B&Pcforthisxas4jon ` - + /)
ne� WORKER'S COMPENSATION DECLARATI ✓
Data
Ihereb afrm under penalty of perjury one of Oc following declarations:
(have and will maintain aCcnificate of Continuo self-insure for Worker's Compcm ( 1 1 Q
sation,as provided for by Section 37M of Ne la Wr Code,for the performance of the >, J
work for which Nis permit is issued. U
❑I have and will maintain Worker's Compensation Insurance,as required by section
7]00 of Ne labor Codc,far the performance of Ne work far wM1icM1 Nis pemtit ix issued.
My Worker's Compensation Insurance carrier and Policy number art:
Cartier. Policy No.:
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(Thu sccom need not becompleted if the permit is formic hundred dollars(5100)
,it uses)
1 canBy Nm in Ne performance of the work for which Nis permit is issued,I shall not -
cmP1Oy any person in any mannerso As to become subject to the Workers'COMNOVOion
Laws of California.Date
Applicant
NOTICE TO APPLICANT:H.after making On CertiOcam of Exemption,you should
become subject m the Worker's Compensation previsions of the Labor Code,you man
.JO foMwit,comply wit such provisions or this permit shall lc deemed rooked.
Z" CONSTRUCTION LENDING AGENCY
I hereby than Nat Nene is a cmnmuction lending aged,for the performance of
C(i
the work fur which this permit is issued(Sec.3097,Co,C.)
SA Lender's Name
=z lender's Address
U O 1 certify that 1 have mad Nis application and state that the seem informed..is
D. f" correct.I agm.to comply with all city and county ordinances and sum laws relating to
OWilding conswction,and hereby authorime mpresenutiws of this city m enter upon the
Y'U ahovcmentiuned propcny for inspection purpoxa ///```
gy (We)agree m save,indemnify and keep ham less the City of Cull ir.against /
F" N liabilitica,judgments,costs and expenses which may in any way accrue against said City
U Z in conmqucnce of the granting of this permit, l
^' APPLICANT UND RSTANDS AND WILL COMPLY WITH ALL NON-POINT Issued by: DatPl
SOURCE REqWeWS. 9 �(�6 __
_ •-� f' Re-roofs
Signe M ofA anuCmnu cmr Date
HA2ARDOUS MATERIALS DISCLOSURE Type of Roof
Will pplicam or future Wilding Occupant store or handle havandous material
As defined by the Cupertino Municipal Code.Chapter 9.12,and die Health and Safety
ode.Section 25532(a)? All roofs shall be inspected prior to any roofing material being installed.
❑Yes aw.
Will the applicant or future building omupant use equipment or devices which If a roof is installed without first obtaining an inspection,I agree to remove
mit havadous air contaminants v defined by the Bay AM.Air Quality Management all new materials for inspection.
District? ` u
❑Yes �4a
Ihavemad thehvardnusm=Aalstcquimmenuunt rChapter6.950rumCalifor-
niaHc IO&Safny Code,Sccumm25505,25533and25534.Iunderavd lhaidthe Wilding
Jas not currently haw a mnank that it is my mapoosibiliry At nod,tic occupant Of the
myuione,4 rox which mu sect prior winstance Ora[cdficam oflxcupancy. Signature of Applicant Date
O,,a5r or autumn. gent ......�•o All roof coverings to be Class"B" or better