05030262 CITY OF CUPERTINO w *`� +^� »bra^"`� au", "` "
BUILDING DIVISION PERMIT �C�NTRACTORINF,ORMATION
BUILDING ADDRESS: PERMIT NO.
05030262
OWNER'S NAME: PERMIT LSSUE DATE
SANRARY O.
E:
ONTROL NO.
ARCHITEC lENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
0 0 0 0
j00 LICENSED CONTRACTOR'S DECLARATION IobDescrition
tuC!-! 1 hereby affirm Nat I am licensed under previsions or CM1spur 9(curanum ng p
iW with Scetior,7")of Division 3 of Ne Butirau and Profamions Code,aM my licers is
y in full fora and efrcm
qg
License class �.9 TI--PARTITION WALLS
F a Dao
ARCHITECTS DECLARATION
W t arc
1 undersand my plans shall he used as public enrCs
>V
o� Licensed Prefessimal
OWNER-BUILDER DECLARATION
x 1 hcrchy affirm that 1 am exempt fmm stns COnwnors License Law for the
00 following lesson.(Section 703 1.5,Business and Professions Code:Any city Or county
m which rasito u a Permit to eAnswct.alter,improve,demalAh,As repair any abucam
I< poor in its issuance.alio nquin¢the applicant fat such Permit to File a Signed statement
Npursuant rew
at he is licensed pursuano the previsions of the Conctur's Lianas law(ChaNcr 9 Sq.Ft. Floor Area Valu hon
r$ (commencing with Section 10110)of Division 3 or Utc Business and Professions Cam)or
that he u exempt therefrom and fit basis for the alleged exemption Any violation of
Sudan 1031.5 by any applicant for a pewit subjects the applicant to a civil penalty of 3.ArD#T.a.T...*qr0 0 Occupancy Type
not moa On five handrail dollars(ssoo). O 7.Js0lY.S�Y
o 1,as owner or On prepeny,m my employees with wages as their sole compensation,
will do the work and On swnute is not inu bed or oncred foe sale(Sun.701a,Business
de:
and Prormathmi CoThe Caauacrcri uansas e Law doant apply inan Owner of Required Inspections
property lwho ows,ids a i d thitu dtaon and who am
wmk M1imslfmthrough h1. j
awAs employees,Provided Nor improvement
4=14 vri as vote ear orc aroRcm fuarsalb�the Own If,
builder Ne building the
tar den of mcnt u sold within arc year of Improve for
the owe r.
of
builder will Mw de hordrn of proving Nat k tlitl not build a improve fm puryom of
0 1.1,as
ea WTef or" prapeny,am exclusively mesand est ressiong with Ii run,CeonwebR W /
construct tic Drv)ea(Sec.o.. Business and Pro(evdons Code:i The Corwnori and. 0
arae law dao rot apply a an with
a of pmprny who builds or improves Conon,and C\
who conuacu for loch pmjecu riN a ewtrssrcr(s)licensed pursum rc Ne Conwaors v
r-II.taw.
am ucmpt undo Sec .B h P C for Nis reason
owner Data
WORKERS COMPENSATION DECLARATION
1 hereby alarm under penalty of perjury one of Ne following declarations:
I have and will maintain a Certificate of Ganem m ulr.i 1mro for Workers Compere
smion,u provided for by Section 3100 of the labor Code,,for the performance of are
work for which this pewit is issued.
1 have and will maintain Workers Continuation Insurance.as required by Section
3100 of on,labor Cade,for the performance of the work for which this pewit is issued
My Workers Compensation Insun me canner and Policy number art:
Cartier Policy No.:
P
CERTIFICATE OF EXEMPTION FROM WORKERS' '
COMPENSATION INSURANCE
(This sectio need not keomplemd if the parrot H fare=hundred Molars($100)
m Mss)
I unify Nm in Ne performance of On woh for which this permit is bound,1 shall ma
employ,any person in any manner so as to become subject to tic Workers Compntetion
Laws of California.Dam
Applicant
NOTICE TO APPLICANT:IL after making this Ccnificate of Exemption.you should
become subject u,On Workers COmpcnsation provisions of the talar Cade,you must
z farshwith comply with such proosin.or this .it shall m dremM revaked
. O
y CONSTRUCTION LENDING AGENCY
1 kmby,(rims Nat thea is a construction leading agency for the pertamana of
the work fa which this pewit Y issued(See.309(,Civ.C.)
QL<nders Name
z Lomisrs Add.
I cmtiry Nat I Ma rad this application and but thm Ne shote infowatiun u
F coram I agree to comply with all city and county otdinarces and sum tan slating to
)O building compunction.and hereby audiorine aprtaentetivu of this city to enter upon the
W ahove-mentioned Pmpcny for inspection purposes
(We)agree in save.indemnify and kap lawless On City Of CayedlnD against
y liabilities,judgmcna,costs andrxpc.which may in any way accrue gainst Sold City
Z in mLIthis
ND
APPLICANT UNDERSTANDS AWILL COMPLY WITH ALL NON-POINT Issued by: Date
SOURCE REGULATIONS,
Re-roofs
Signature of ApplicanVContracmr Data
HAZARDOUS MATERIALS DISCLOSURE Type of Roof
Will Ne applicant or future building oes upsomsms m handle,hvardous material
as defiocd by the Cupertino Municipal Cock.Chapter 9.12,and Ne HcaIN and Safety
Conn.Samoa 25532(.)1 All roofs shall be inspected prior to any roofing material being installed.
❑Yu ❑Na
Will the applicant or future building occupant use equipment or devices which If a roof is installed without first obtaining an inspection,I agree to remove
mit hanNau air common...as defined by Ne Bay Ansa Ail Quality Management all new materials for inspection.
District?
QYu ON.
I have Sad On harardaus materials squircmems under Chapur6.95of Ne Califor-
nia Hcal"SafvyCode,Sections 25505.M533 and 25534.1 taxi named dm if Ne,building
does not currently hot a mnanL Nat it u my lesponsihilny to notify de oaupant of the
mquiamentawhich must kmet poor tuiasammcofaCertificate OrOccupancy. Signature of Applicant Date
Owner or uOomsd agent Dam All roof coverings to be Class"B"or better