04020090 CITY OF CUPEWrINO .&�," £s
BUILDING DIVISION PERMIT WONTRAC-'TORiINFORMATION
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BUILMN fD �$S: PERM.NOh4OZOO9O
Is2R'S NAME:/ 24 PERMIT ISSUE DATE
IR
111/2
PHONE: SANITARY C OL NO.
ARCHITECT(ENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
0 0 0 0
u00 LICENSED CONTRACTOR'S DECLARATION
<�C 1 Mmby affirm Met 1 un limned under pmvisio�as of Chapter 9(commencing Job Description _
-^�b with Soclon]IXgBaf Division 3af me Busincalmd Pmfcumns Cmu.mdmylicense is.
a. in full force and cffmer
y_ License Cho Lie.• REVISIO --FL. PLANS CHLCS
Dam cmmeCctor
DECLARATION HGU: USE ONLY, NO NEW PERMIT ISSUED
-n9
E2 ARCHffECTSD
I understand my plans shallM used u public records ORIG. #03030090
a.�yU
3 01 Licensed Professional
O1 Oat I am eU rep,from
DECLARATION
1 hMaso alarm Net 11. .umpt Rum the Cssion; fs License law for the
m o O following reason.Permit
u ID3s 5,Business and Sae,de mm Calc:Any city s county
K$ which regisms a permit ac construct.Rlma improve,h Permit t are pair any etmerum
v-'^ priormits issuance.also requires the applicant for such permit to hie asigned summcnt
FSC rsu
Nal he is licensed pursuant 1.thepmvisiouofMeCaoracmfsLima.Law(Chapmr9 Sq. Ft. Floor Area Valuation
yl- (commencing with Section 7")of Division 3 of the Business and Professions Code)at
y $ Nat he is commit theofroo and On buss for the alleged exemption.Any violation of
Section 7031.5 by any applicant for R permit subjects the applicant to a civil Penalty of APN Number Occupancy ype
not mom than five hundmd cWhom($5110).
I,as owner of the property,in my employees with wages as their vele compensation,
will do MewaA..oil Matureismismit intended oraffixed far W.IS".7W.Bnsw.. 36938038 . 00 Required Inspections
and Professions Code:The Canuacmfs Licertse Law docs not apply to an owner of
prnptny who builds or improves Manion,and who doessuch work himself or through his
own employees.provided that such improvements art not intended oroRemd for We.If.
however.Ne Wilding or improvement is sold within one year of completion.Ne owner.
builder will have the burden of proving cut be did act build or improve for purpose of
Salt.).
I,as owner of the property,am exclusively maintaining with licensed mnua.to
nstmct the project(Sec.]OMs,Business and PmfeuVons Code:)The Contrwous's Li CVVtt
more law does not apply in an owner of pmpeny who builds or improves thereont and
who contrutsfafsuch projc< with acontnapKs)liansed pursuantmthe Conurtofs
License law.
am ezcyy, .Bk PCnor this mwmn
OXWORK SMP TION DECIANN
1 hereby alarm under Penury of perjury ane of the following d¢I t=I.ons:
[him and will maintain aCcnific ar of Consent m self-insure for Worban sConnKn-
Winn,IS provided for by Section 37W of the Labor Code.for the performmtce of the
work for which this permit is issued.
M I have and will maintain Worker's Compensation Insuran¢,as retained by Section
3700 of the Labor Code,for the performance of the wart for which this permit is issued.
My Workefs Compensation Insurance carrier and Policy number am:
Camey. Policy No.:
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(This Section need not he completed if the Permit is formic hundred dollars(SIM)
or less.)
1 certify Nat in Me performance of the work for which this permit is issued.I shall nut
topic,any person in any manner so as an become subject to the Workers Compensation
Laws of California.Date
Applicant
NOTICE TO APPUCANT.If,after making this Ccnincate of Exemption.you should
become subject to the Worker's Compensation provisions of Ne labor Cade,you must
JO forthwith smply with such private.or Nis permit shall M docmcd revoked.
H� CONSTRUCTION LENDING AGENCY
1 hereby afRrm J
that there is a construction lending agency for the perro mance of
CLQ Ne work for which this permit is issued(So.3097,Civ.C.)
It]Q Lender's Nene
C Under's Addross
U C) I«nify Nat I have read this application and suss that the above infornatiun u
ly F cancer.l agme to comply with all city and county oNiunces and sum laws misting to
0U building construction,and hereby authorise mpmsenutives of his city In enter upon Ne
�I37 ahovc (We) ical
property save fodcomi yion purpose¢
,r 1 (We)agme to save,indemnify and keep harmless the City of Cupertino against
rA liabilies,judgments,eosts and expenses which may in any way accrue against Said City
U in consequence of the grand t ' t.
'-' APPLICANT UNDfN�DM$ D LL COMPLY WITH ALL NON-POINT Issued by: Date
SOURCE gEGUCA'PjGtj6. I
t`tom Re-roofs
Sin mal'ApplicaMConuaemr � (��ty
HAZARDOUS Ar,uccu S DISCLOSURE\A•l w' Type of Roof
Willy McCuKrunt rfuture abode.chaptsmrcor hanand fth ismmnJ
efined by Nc Cupertino Municipal Code.chapter 9.11,and the Health and Safety
c ❑Yes 35532(°)1 No All roofs shall be inspected prior to any roofing material being installed.
rWrf`l, If a roof is installed without first obtaining an inspection,I agree to remove
Will Ne applicant or future building occupant use equipment or devices which
emit havardnus air contaminants as defined by the Bay Ars Air Quality Management all new materials for inspection.
District? y
❑Yea
1 have mad the ha da dmen materials requirements under Chapmr6.95 offt Califon
nia Health k SafctyCom,Scemu 25505,25533 and 2553¢.I und emuid MaHfMa Wilding
does not currently haw a tenant Nan it is my res ne[iry in war Ne occupant of the
mquiremcmewhiehnouttot Z t tau f.CeniBeateofOccupncy Signature of Applicant Date
— ff
Doraramhmrudaget, - Dimf All roof coverings to be Class"B" or better
I ,