05070074 CITY OFCUPERTINO
BUILDING DIVISION PERMITCOkNTRACTOR TNFOIRMAT,10,N,,;i
BUILDING ADDRESS: PERMIT NO.05070074
OWNER'S NAME: FERMIT ISSUE DATE
9TT.VF!R,qTQNF, QR/29/200S
E; SANITARY NO. CONTROL NO.
ARCHIIECT/ENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
O O O O
�oz LICENSED CONTRACTOR'S DECLARATION Job Description
Ill 1 WrOy affirm Wt 1 am licensed argue provisions of Chapter 9(commencing with with Section 7")of Division 3 of the Business and Profmiom Code,and my license is
^ in full forte and affect
flz LlcnraClnaa Lie.0. (J31 RETAIL-SHELL ONLY
Data Canwcmr' /EIL
ARCHITECTS DECLARATION
I understand my plum shell be used as public rcco is
3 i sad Licenced Professional
N OWNER-BUILDER m the Com ION
E 0 I hereby antrm Net 1 I.S.exempt from the Comracwes License Law for the
e o which re maven.(Semon 703 1. t,Business and improve.
de oli Code:Any airy structure r ry
$ which myulms a permit re Camas the alar,nt rrow,he ermit t fi repair any eme $2000081
Odor ler itsiassed pu matzo the thovisio so far such Permit to Ne as Law(mtement
< (Out W commencing adOuewan71)(1 )ofDivision
iviomofNcCoinsiness LicemlimmuCWpur9 Sq.Ft.Floor Area Valuation
$
that
he
exempt
pt Section it On
Inch al of the al Business tendon.my
Calc)or
— Nu io ts excerpt theaclrom ant the huh forthecgs alleged exemption.to Any violation of
Salton dim by any applicant for•permit subjects the applicant a tlWl penury of c Occupancy Type
not mom Nan an hundred dollen($SW).
D 1,uownerof Uepropenymmyemploymwuhwgesuthclwletompe Uon,
will do de wark.and the immune Gnat intendedmoffead forsale(Sec.70th.Business Required Inspections
and Profusion,Code:The Cormonaor's Liceme Law dm e not apply m an owner of q P
propenywho Wildsorlmprows thereon,and who dmsuchworkhimwlforthrough his
own employe¢,provided that such Improvements ere notimmnded aroRered for sale.If.
however,the building or improvement Is sold within one year of completion.the owner
builder will ism the human of proving that he did not Wild or improve for purpose of
ante.).
D 1,as owner of On,property.am exclusively contracting with licensed anummors m
comma tie project(Sec 70M,Russians and Profesuarts Code:)The Consommes U.
cease Law dos nm apply at an owner of pmpmy who Wilds or Improves theaan.and,
who contracts for such projects with s eonmctor(U founded pursuant to Use Contractor's
Licence Law,
D 1 am exempt under Sec. .B k P C for this reason
nor Dam
WORKER'S COMPENSATION DECLARATION
I hereby affirm under penalty of perjury am of the following declamlan,:
❑I Nw eM will matnuin aCemficeseaf Convent m selFinsuse(m WarMaCompen-
scion,u provided(m by Section 3700 of the labor Cade,fm the performance of On
work for which this permit is issued.
D 1 haw and will maintain Wmkces Compensation Insurance,u acquired by Section
3700 of the ISWr Code,fm the perfarmance of the work for which this p emit is lurned.
My Wmimen Compensation Insurance carrier end Policy number art:
Cantee'Li AiCH -AgC- ICA poliq No.: WG 3633 1 S
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
This smedon need not w completed If the park is(maw hundred dollar($I W)
or leu.)
I certify mot in the performance of the work for which this Permit Is imund,I shall not
amplay any person in any manner.as m became wbjal to the Wosken'Compmeadon
LA.,of C.1iforn a.Dam
Applicant
NOTICE TO APPLICANT:It,after making this Certificate of Exemption,you should
become subject in the Worker's Compensation prevision,of the labor Code,you mum
,J O forthwith comply with such provision or this permit shall be deemed revalued.
rN~. CONSTRUCTION LENDING AGENCY
[ti I hereby alflrm that mem It.commotion lending agency fm the Performance of
athe work fm which this permit ts blued(Ste.3097,Civ.C.)
Name
-
4 Q Undoes Na
Q z Leader's Address
U Q 1 certify that 1 haw cud this application and state that the shave Information Is
ly^. cmmn.1 qac m comply wine all city end county ordinances um sum hens relating to
Q rV' Wilding commaka.and hereby stahmirs apreanWiws of this city to enter upon the
above-mentioned property for lnspecaoo purposes.
(We)agree to saw.indemnify and keep hannlm the City of Cupertino against
fA
liabilities.judgments.costs and expenses which may In any way acme againslaald City
U,� in consequence of the graining of this permit.
w+ APPLICANT UNDERSTANDS NO WILL COMPLY WITH ALL NON-POINT Issued by: Date
SOURCE REGULATIONS.
— r a�9�°r Re-roofs
signuu eanUContnetor a—�
HAZARDOUS MATERIALS DISCLOSURE Type of Roof
Will the applicant or future building occupant atom or handle hazardous material
as de0ned by the Cupertino Municipal CadeChapter 9.12,and the Health and Safety
1!a�
tion 25532(.)? '// All roofs shall be inspected prior to any roofing material being installed.
Yes t7Neill the applicant or future Wilding occupant use equipment or device which If a roof is installed without first obtaining an inspection,I agree to remove
rdme,oI,contaminants u defined by tW Bay Area Air costly Management all new materials for inspection.
,/Yes I�'f+uue mag the huamm s materials requirements under Cheper6.95 of the Califonk SafelyCoue,Sccdom 25505,25533 and 25534.1 understand that if t e building
amordy hew a u cant.Nett ' y respemthilllymmtily themaroonofthe
ntswhmhm Waimpti aauc a fa CmtAmw of ecu Signature of Applicant Date
thadxea gent Date All roof coverings to be Class "B"or better