04090091 CITY OF CUPEWrINO-• � ' ww�s.
_. ROILDINc DIVISION PERMIT CONTRACTOR INFORMATION
BUILDING ADDRESS: - PERMIT NO.
04090091
rR NA E:BE PtNZA PERMIT ISSUE DAIS
E:
SANITARY OL NO.
ARCHIIECf/ENGINEER: BUILDING PERMIT INFO
_, BLDG ELECT PLUMB MECH
�Op LICENSED CONTRACT'OR'S DECLARATION -
y I bereby affirm that I am limnmd under provisions of Chapter 9(commencing .Job Description .
<_ with$mtion 7ak)t ofDivisionJof the Busimss and Prnr[ssinmeoae..namy Gcenm i5 - -- - - - --
'^ Nin full forte and effect.
oqA, class cane 500 GALLON PROPANE TANK
Do
's Dater Contractor _ - --
W3 A0.CHf1ECi'S DECLARATION
�e< I understand my plans shall he Wind a public raords
D-U
o Licensed Professional
OWNER-BUILDER DECLARATION
9 hereby affirm that 1 am exempt from We Contractor's Licenser Law for the -
E p o following mason.(Secuon 7031.5,Business and Profcndom Code:Any city or county
m(L which nouims a permit to cnmtmcL alter.improve,dcmolL h,of repair-any machine
prior to its issuance.also rectums the applicant for such permit m file a signed matinord VU
t3'<
that Wislicensed p rmamtnmepmvi55ot�pfthecnmraetn SUker eLAW h.p�m9 Sq.F[.Floor Area 'Na ver
re (commencing with Section 7")of Division 3 of the Business and Professirm Code)or
As
$ door he is ssempt therefrom and the basis for We alleged exemption.Any violation of -_
Section 7031.5 by any Appricarn for a permit subjects We applicant m a civil penalty ofOp y Type
not mare man five hundred doll..($500): 3 "t "O 0 ccu ane T e
1,na owner of the property,or my employees with wages As their able compensation,
will ded We work and We atructum is not intended or offered for ale(Sm.7614,Busincas
And Pro(erawas Code:The Conuacmr.Lina..law does natapply m An..or - Required Inspections
prepeny who builds or improves thereon.and who does such wart himself or through his
Avon employees,provided mat such improvements tie nmin Luded oro@red for We.IL
however,We building or improvement is mid within on year of completion,We owner-
builder will have the Wrdm of proving fun W did mat Wild ar improve for Purpose or
aalc.).
11,as Owner of We property,am exclusively contracting with licensed mammime to
o eruct me pmjecl(Sec.7044,Business and Professions Code:)The Contractor's Li- -
comm law does not apply to an owner of property who Wilds or improves menton,and
who contracts for such proXcts with a conwcros(s)licensed purauant to me ConuactoYs - -•
License law.
❑lam.,in n r C. .B&PC for is mason -
Owner Dae
W RK COMPENSATIONDECLA
1 hereby affirm under penalty of perjury am of the following declaradom: -
IhaveandwillmaintainaCertificate of Cmtscnl to self-insure for WorkcisCompcn- .._. .
mono,As provided for by Section 37th of We labor Code,for We performance of We
work for which this permit is issued.
1 have and will maintain Workers Compendium lumrance,As required by Section - -
37WofineLabor Code.for me performance,of the work for which this permit is issued.
My Worker's Compcwtion Inwnna carver and Policy number am: -
Carrier. Policy No.:
CERTIFICATE OF E)(EMP ION FROM WORKERS'
COMPENSATION INSURANCE -
(Ibis.etoc mN not be completed if tbe pr.iL is fart..hundteddmlam(SIM)
Or Ices.)
I certify,mm in me pc,mrmanto of the work for which this pemai,is issued.I Abell nut
employ day pcumn in any mannerm ss to Wcome subject to We Workers Compensation
IowaCdifbroii Data /
Applicant
NOnCE TO APPLICANT:If.after making this Certificate of Exemption,you should
becomebome subject the WortCompensation provisions of We Labor Code.you mum
.,O forthwith complyy with such
Compensation provisions or this permit Shellbedeemed revoked.
Z '^ CONSTRUCTION LENDING AGENCY
[-.4 I hereby alfinn mat Were is a construction lending agency for We performance of
(Y > me work(or which this permit is issued(Sec.3097,Civ.C.)
WW Q Lenders Name
=Z Lenders Address
U O 1 certify that I have tend this application and sate mar the above infotmatiun is
W P mmol.T agree re comply with all city and county ANinanes and Aute laws relating in
OU building construction,and hereby authoam mpmsentetives of this city to enter upon We
r W ahow-mentioned property,for inspection purposes.
f+0. (We)agree In save,indemnify and keep hdmless me City of Cupertino against
N liabilities,pcignumW case and c.,.5 which may in any way acemc.&emit said City
U Z in consequemc of We granting of this permit.
^+ APPLICANT U ERS N AND WILL COMPLY WITH ALL NON-POINT Issued by: Date
SOUR G A
y Re-roofs
u of App is onuanar Date
HAZARDOUS MATERIALS DISCLOSURE Type of Roof
Will me applicant or future Wilding occupant store or handle hazardous material
n defined by the Cupertino Municipal Code.Chapter 9.13,and the Health and Safety
Cole.Smtion 25531(.)? ee,,..�� All roofs shall be inspected prior to any roofing material being installed.
❑Yes y No
Will the. ueanlor/m`ore building«cu ant try[equipment arur.ica wmm If a roof is installed without first obtaining an inspection,I agree to remove
applicant B v
dl hazardnas air contaminants As defined by me Bay Arta Air Quality Management all new materials for inspection.
Distrie,?
❑Y.A
1 have mad the ba.dour materials requirements under Chapter695 of the Califor-
niaHealth&Safny Code,Sections MM5.25533 and 25534.I unJersund muifmc Wilding
rims not cunen0 M1avc a/p n ml it is my mapbnsibility m teary We occupant of We
tequirtmcntsw c ma(Cosa brwissumccora Cenlfieadof Oce ex Signature Of Applicant Dale
��� � -- All roof coverings to be Class"B"or better
O or am a is agcm Drina