04010013 CITY OF CUPEWI'INO a�a ^Jo��sa ' •
BUILDING DIVISION PERMIT �.CONTRACTM,11NFORMATION
BUI[.DING ADDRESS: PERMIT N00 4 0 10 0 13
G2 0 2 DE AINZA, 'RT 171D
NER'S NAME: PERMITISSUEDATE
ONE: SANITARY NO. CONTROL N0.
ARCHITECT/ENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
u000 LICENSED CONTRACTOR'S DECLARATION
w recorded hereby affirm that I recorded under provisions or Chapter 9(commencing Job Description
Zoy wire section 7(l)gnroivW.o 3or Nc Bmincssand Profession,Codc,red in,fetor le
;�? Licevin fuend coat.
mclassLk.as _a EXPIRES 02/06/04
o—'3 ARCHITECTS DECLARATION
o Dam DAYS PERMIT cnmmetORIG. #03030090/TEMP PERMIT #03110117
f
J,< 1 undcrsland my plans shall M used as public records
g U
Qh Licensed POccasional
g OWNER-BUILDER DECLARATION
I hereby affirm Na T am exempt from the Contractors License Law for the ..
n O following mason.(Section 7031.5,Business and Professions Code:Any city or county
K m which myuires a permit to construct,alter,improve,demolish,or repair any structure
prior to its issuance,also requites the applicant for such permit to file a signed statement
ra that he is henrived pursuant to the proviridns of the Contractor's Liccaso Law(Chapter 9 Sq. Ft. Floor Area Va�2t#)4900
xFC (commencing with Section 700d)of Division Sof the Business and Profcssinns Coat)or
i
that he is exempt therefrom and the basis for Joe alleged exemption.Any violation or
Section 7031.5 by any applicant for a permit subjects the applicant no a civil penalty of APN Number Occupancy Type
act more than firm hundred COR...
Pane Y YP
Q1,is owner ofthe property.or my employees with wages u moor sole compensation, 36938038 . 00
will do the work.and On structure is not intended oratrered for sale(Serc.7W.Business
and Professions code:The Contractor's License Law dors not apply to an owner of Required Inspections
property who bullas or improves thereon.and who does such work himselror through his
Own employees,provided Nat such improvements arc not intended or offered forsale.If,
however,the building or improvement is sold within one year of compkuan,the owner-
builder will have On burden of proving Nat he did not build or improve for purpose of
salt.).
I,es owner of me proRfty,am exclusively contracting with licensed contractors m
co rvct the projcn(Sec.7(104,Business and Professions Code:)The Cnnvnhur's Li.
terse law does not apply m vn owner of property who builds or impresis Merton,and
who commc rojccts withn conmcmr(s)lianxd pursuant to Ne Contractoh
❑I cacmpt and Inc. ,Bate— t7mn ��1\
WORKERSCOMP ATION DEC 0.A N� - V
I hefeby affirm under penalty of perjury Co.of the following declamations:
I have and will maintain s Certificate of Consent self-insum for Worker's Compen-
sation,as provided for by Section 3700 of the labor Cade,for Ne performance of the
work for which this permit is issued.
Q 1 bars and will maintain Workers Conepnuuion Insurance,u teyuined by Section
37M of the labor Codc,for the performance of the work for which this permit is issued,
My Workers Compensation Insurance carrier and Policy num her art:
Cartier. Polity No.: _
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(This scnion need not he completed if the permit is for one hundred dollars(S100)
or Mss)
1 ccnify that in the performance of On work for which this permit is issued.I shall not
employ any person in any manner as as to become subject o the Workers Compensation
Laws of California.Date
Applicant
NOTICE TO APPLICANT:If.after making this Cenificam of Exemption,you should
become subject in the Workers Compensation provisions of the Labor Code,you must
.J ,Z forthwith comply with such provisions or this permit shall h deemed revoked.
ZO CONSTRUCTION LENDING AGENCY
[-+ I hereby oRrm Nat then is a conswcdcor lending agency for the Performance of a
C( �
On work for which this fermit is issued(Sec.3(197,Civ.C.)
W Q Under.Name
Z Lender's Address
V Q 1 certify than 1 bare nad this application and train Nat the about information is
W P correct.l agree W comply with all city and county ordinances and state laws relating to
0 t building constructom,and hereby authorim represemaliwa of this city to enter upon the
W ahovcmentionW property for imPecuon Purposes.
(~ gy (We)ago indemnify and trop harmless the Ciiy of Cupertino against
h liffiilidofj ens,costs ntlexpea which may in anyway accmc against said City
U'Z in conn race of Ran 6 n hisfit)t.
'^ APPL A§UND DS AND WILL COMPLY WITH ALL NON-POINT Issued by:3 Date
5 ERe-roofsSign are antrum oars
HAZARDOUS MATERIALS DISCLOSURE Type of Roof
Witt theapplicantmfuture builtlingoccupant storeof handle Health and
u defined by the Cupertino Municildf Code.Chapter 9.12,and site Health and Safety
Jc,Section 25532(x)+ / All roofs shall be inspected prior to an roofing material being❑Yea p p � Y g g installed.
Will mea applicant or future building Occupant use t or devices which If a roof is installed without first obtaining an inspection,I agree to remove
pP s p equipment
it hazardous air Contaminants defined by the Bay Arca Air Quality Management all new materials for inspection.
ianrico
QYes No
I ban re chore ousmaterials requirements under Chapter6.95 oldie Cellfor.
nia Haalm& coy Cade, nm25505.25531and2553a.lundcrsuu .ifmc Wilding
does not cu ntly have a ant,that it is my respoddihiloy 0 nndly the Occupant of the
reyuirt akWhich tome nisspanaoraeeruficamprOce aney. Signature ofApplicant Date
of,oranmoa,<dagea. Do. All roof coverings to be Class"B" or better