06120016 CITY OF CUPERTINO
BUILDING DIVISION PERMIT CONTRACTOR INFORMATION
BUILDING ADDRESS: PERMIT NO. 06120016
S DE ANZ
OWNER'S NAME: PERMIT ISSUE DATE
SILVERSTONE
SANITARY 10, 9 CONTROL NO.
WE
ARCHITECT/ENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
(= C= 0
00 LICENSED CONTRACTOR'SDECLARATION IObD0SCT1 non
w F 1 therebyaffirm that 1 am licensed under provisions of Chapter 9(commencing P
with Section 7ODD)of Division S of NC Business and Prelcsuov Code.and my limit it
!�N Wfull force andeflim. REVISION: SANITARY MAIN LINES THAT ARE EXITING
License Class Lie.a
BUILDING
'y Dan-Contractor
ORIGINAL PERMIT: 06110011
understand my plans shall be kind It public remorals
iyU
°oH Licensed Professional
OWNER-BUILDER DECLARATION
<f 1 hereby SIThm that I oro cacmpt from the Cantncmr's License Law for Wo
p o following moon.(Section 71D L5,Business and Pmfersuons Code:My city or county
which re,iry a permit to Construct.alto[improve,deans h,or repair any Structure
Z< prior to its issuance,also requires the applicant for such perming file asigned su¢mcnt
that he islicensed pmWanttothe provisions;ofthe CmuacmrsLicense Law(chapmr9 Sq.FL Floor Area Valuation
(commencingwith Sccsion7000)of Divuion3o(Oc Buunmand Professions Cndc)or $3035479
s $ Nat W u exempt tbemfmm and the buts for the alleged exemption My violation of
Section 7031.5 by any applicant for a permit subjects the applicants on a civil penalty of APN Number Occupancy Type
not more than five hundred dollars(5X10}
❑1,as owner of the property.or my employees with wages v their sole compensation,
will do the..,it.and the suderem W not Smartest o offered for rals(See 70th,Busircst Required Inspections
Slid Pmfessios nCode:The Cmntrsber License Law does trot apply m an owner of q P
property who builds or improves therecn,and who does such work himself or through his
awn employees,provided that such improvements are trot intended or offered for sale.IL
however,the Wilding or improvement W sold within am year of completion,the owner.
builder will have the land.of proving that M did rot Wild or imprwc for purpose of
sic.).
0 I,v owner of the papery me exclusively conuauing with licensed cenuamms or
construct the project(Sec.7004,Business and Professions Code)The Conuacmb Li.
cove law does misapply w an owner of property who Wilds or improves thereon,and.
who contracts for such projects with a contractor s)licensed pursuant a the Conmemer
License Law.
❑I am exempt under Sac .B&P C for Nis season
Owner Due
YORKER'S COMPENSAT19f DECLARATION ,
1 hereby airum under pcvlty of perjury m of the following declarations:
have and will mountain a Ceadfeme of Consent to self-insure for Worker's Compen-
a6on,as Provided for by Section 3700 of the label Code,for the performance of the
work for which this permit is issued.
❑1 have and will munain Workers Compensation Imes.,as required by Section -
37W of the Labor Code,for the performance of the work for which Nis permit is Issued.
My Workers Compensation buurance artier and polity number are:
Cartier. Policy No.: _
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
Thusctiw need not W completed if the Permit is Income hundrddri(1I01)
or loss.
I certify that in the pertormarme of the work for whleh this permit is issued,l still our
employ any person in any mannersWasm�cmmc ubjca m Om Workers'Compenauon
JAWS of California.Dau—1'L/15 A.S� /
Applicant /12.h�-��-.r � �
NOTICE TO APPLIC ::I�ner making this CordifirplK of Estimation,you should
become subfeet to IW Worker's Compensation provisions of the Labor Code.you mot
.J ,z forthwith comply with such provisions or Nis peanut me]be deemed leveled,
zCONSTRUCTION LENDING AGENCY
(••�� IbelehyafRrm that them is a custax6rn lcndingagcney for the prfomnance of
CC the work(Lir which this Permit is rood(Seo.3097,Civ.C.)
QLender's Name
z Lenders Address -
U Q I certify that 1 have mad this application and sate that the Shove information Is
U, correct.I agree to comply wit all city and county ordinances and sate laws relating to
C) building eomaructmn,and hcrchy authorim represematives of this city to crier upon the
Wvo-et,J.,red property roe parany wgases.
Ira 0. (We)agree to save,indemnify and keep harmless the City of Cupertino against
r/3 Iiabiliues,Judgments.costs and expenses which may in anyway accrue agunst said City
(„)Z in commap enee of the gaming of dint per it.
APPLICANT UNDERSTANDS AN ILL COMPLY WITH ALL NO Issued by: 60 Date
SOURCE REGULATIONS. �,,�
r �"� 12�L Re-roofs
Sign'd1YR(nMppincaltl/GnnllMlOr m
HAZARDOUS MATERIALS DISCLOSURE Type of Roof
Will the applicant of future Wilding occupant store or hvidle hansrdov mamrial
as dented by ted Cupertino Municipal Cade,Chapter 9.12,and the Health and Safety
Cade.Section 25532(s)?"Yess pHm All roofs shall be inspected prior to any roofing material being installed.
Will the applicant of future Wilding occupant a c equipment a devios which If a roof is installed without first obtaining an inspection,I agree to remove
iI hvardoki air contaminants as dcftncd by the Bay Ama Air Quality Managcmcnt all new materials for inspection.
DisuicR /
CI year jY
rNu
I have mal the hvardmumateiials mgti emenuunder Chapter6.95 ofthe Cabror
nig Hcalth&Safety Code,Sections 35505,255 and2534.1 understand thuiftem Wilding
dos not Carmody have a mmol that it rvponsibility m no'fy theoccupant of Ne
¢gnimriic�which mesa mere pries anracerrdrp�a faaPtnty. Signature of Applicant Date
Owner of mdm"Cd agent / Dam All roof coverings to be Class "B" or better