06120167 CITY OF CUPERTINO
BUILDING DIVISION PERMIT CONTRACTOR INFORMAT ON
_BUILDs^IVN-G�ADDRESS: L C /ftes PERMIT NO.
EPERMIT ISSUE A
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SANITARY NO. CONTROL NO.
ARCHITEC(ENGINEER: 1—,., BUILDING PERMIT INFO
I s Ie
f4 C,q tPLrBLDG ELECT PLUMB MECH
pop LICENSED CONTRACIOWS DECLARATION
C 1 thereby affirm thus I am licensed under provisions of Chapter 9(commencing Job Description
U who llfamn]dCrIfDiviSionJof the Businev and Pmfessiuns Cndc.and myliccvcu
n in full fume and iffier. I`..l�i t,J/ L l-.CC,.I(,,t' t/\il.f •rte
;yAi License Class Ix.I
Dow Contractor
ARCHITECTS DECLARATION
understand z� I unticrnJ my plans Mall he mud as public records ,
iyU
C y Licensed Pntfcssional
OW NER-BUILDER DECLARATION
<I I heresy affirm Nu 1 am exempt(ming she Conuames License Law for Ne'
i a o following mason.(Swtion 7031.5,Business and Propagations Code:Any city or comedy
I$ which requires a Permit m censuring.cenaet,alcor,improve,dcmnlisM1,nr repair any awmurt
�ai pdarkriuissuarec.alsomquires the applicant forsuch facmitm Tile asignedsulemcm
;R< that ho is licensed Purport to to provisions ofthc commcmr•s Licence,Law(Chapter 9 Sq.Ft.Floor Area Valuation
kl=-n (camtnencing with Sction 7000)of Division 3 of the Business and Pro(euiom Congo)or
$ that he u exempt therefrom and this basis for the alleged exemption.Any violation of
Sectio 7031.5 by any applicant fm a permit subjects the applicant a a civil penalty of APN Number Occupancy Type
tat ort than n m hutkmd dollars(55001
1.u owner argue,Property,or my employees with wages as their aide compensation,
will do Newark,and 0almucsure u maintaining oraRered forsain(sec.JOU.Busircss
and PedfcsdoN Cade The Customizes License Law don mit apply in an arguing of Required Inspections
property who builds orimprowrs thcrmn,and who deessuch work himself ter through his
Own emplayces,provided that such improvements arc not intended ora@red for sale.IL
however.the Wilding or improvement iv said within one year of completan.the owner.
builder will have the burden of proving that M did net build in improve fw purpose of
sil
❑1,as Owner of be property.am exclusively contracting with licensed comraears be
continuo the project(see.70U,Business and Proresmots Code:)The Canuaetots U-
cense Law dos out apply m an owner of property who Wild improves thereon,and,
who contacts for such projects with a c.ntracmr(r)licensed pursuant to dm Conuacmr's
License Law.
I am uempa undeasec .B g:PC for Oil.rea,on
Owned Dem 222
0.KFR'S COMPENSATI ECIARATION
49 1 bemby afrum milder pemisy of perjury one of tat folldwing dalamdmm:
I ham and will maintain a CerdOcam ofCona to self-insurefor WorkeesCempen-
motion.as psevided for by Section 3700 of the Labor Cade.for tat performaxe of slice
work far which this permit is issued.
❑I have and will maintain Wastages Compensation Insurance,as required by Section
3700 of tat labor Code.Or the pedman Ott of Ne work Jr.which his permit is issued.
My Wegener Compassable:Inaronce anise and Policy number art: '
Cartier. Policy NO.;
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE .
(Thu section need not W computed if the permit is formic hundred dollars(SI00)
ter less.)
I aNfy that in be ponfarmaner,of Ne work for which this Permit is issued.I shall rad
employ any person in any mrd%gfso y W hecto snhiecuo the Worker Compcnsaton
Laws of California.Dam _l I.LL LL
APPliam +f-s�?
NOTICE TO APPUCANT�lf,afar making this Cen ficamaof Exemption,you should
become subject a the Walkers Compensation provisions of thc Labor Code,you must
.J z forthwith comply with such provisinm or Nis permit Shall be deemed invoked.
z � CONSTRUCTION LENDING AGENCY
F+� Ihemby afngm that there is a comwction lending agency for the performance of
D: the work fur which Nis permit is issued(Sec.3007,Civ.C.) -
0. A Lander',Name
Q z Leagues Address
V Q I certify Nat 1 have mad Nis application a,a sera that the shove information is
carrier.1 agree to comply with all city and county ordinances and sum laws relating in
QU building conswedion,and hereby a.thimn MPMSenutivm Of this city to enter ipOn the
4 ah.vo-m,judgudpropcat,ly funmpccton pwphms.
(We)agree to saws,indemnify and keep hasrnlau to City of Cupenmu agoing
F' Z inconseque consequence
of th.cmuand ex pansesrmit. may in any way accrue against said Ciry
C)z APPL CANTCUNDERSTANDS Ahe granting of IND It COMPLY WITH ALL NON-POINT
SOURCE REGULATION', Issued by: Date // 'Z-
/2 2z Re-roofs
ignaue of c^nHA�ZARD [)aa
OUS MATERIALS DISCLOSURE Type of Roof
Will the applicant or rut=Wilding acc uPamrtaro or handle haaardam material
as dc0ncd by the Cupertino Municipal cede.Charm,9.13,and the Health and Safety
Code.Section 35533(e)7 All roofs shall be inspected prior to any roofing material being installed.
Yes
If a roof is installed without first obtaining an inspection,I
Will the applicant or forum building occurring use equipment of devices which g agree to remove P
mit hvardnm air cmnuminanu as v< y the Bay Arta Air Quality Management all new materials for inspection. h
District?
❑Yes
I h rvc read the Imudnusmamrims myvirtmenu under Chapmr6,95 of dm Calif.,.
nu Health&Safety Code.Sectors 35505.25573 and 3 5M.I undcrsund haggle,building
dos nod comamly hart a mnnm,Out it is my mspomihilisy m m'y the Occupant of the
myuimmencs which most Wm at prio,1.issuance era Cert( ofOccupancy. Signature of Applicant Date
Owner or aushomed agent . Dom All roof coverings to be Class TO or better