05020075 CITY OF CUPERTINO ": razes
BUILDING DIVISION PERMIT •CONTRACTOR INFORMATION
BUILDING ADDRESS: PERMIT NO.
05020075
1054r4 DRQPAP.A DR P
ER'S NAME: PERMIT ISBUE DATE
MILIr
PHONE: _ SANITARY OLNO.
ARCHITECT/ENGINEER: BUILDING PERMIT INFO -
BLDG ELECT PLUMB MECH
0 0 0 0
�Oo LICENSED CONTRACTOR'S DECLARATION Job Description
I hereby affirm that 1 am li¢luctl tit,provitio M.Clupvr 9(rnmmencing P
yV wiN Section)IX10)of Divirio Busineessano Prof ham Cade.and my he..is
^.<jd (ullfoacondeffm. \\ -� ADD 873 ' (LIV. /2 BEDRM/1 BATH)
i� Dale classConv r
"tq-w AR HITECTSDEC An f REMODEL
1 unW n d my plans hall W uacd m public re ds
Doti
;ay Llecved Pmfcssional
5 OW NEmexemDER DE We Con Clo
00 ON
I hereby affirm on I am exempt from We Convmmr's :Any c Law(or the
p a following mason.(Suites IID L5,Business and Pro.dem m Code:Any city or county
m which myuiros a feast m vires We alter.improve,h Permit ri e pair ed Wmmum
F i y Wal heprior its cetacd p also pursuant
to We Wovisio s of for such Permit 70 hansc,Law(chapter
chs mem
< (co mencin with
pursuant 7000) Commuctars Sq.Ft.Floor Area Valuation
m
Wm
(commencing xcrien]000)andW busisofr W theeged essand
on.An vi Code)or
� Nal he u eaemp,Wrtfrom and Ne bosu for Ne alleged exemption.Any violation of
Section 7031.5 by any Applicator for a armiuubjects We appileanuo a civil penalty of APN Plumber Occupancy Type
not more Nan five hurdrod dollua(5500).
❑1,u owner of rhe pmperty,or my employees with wagesss Weir role comp m,ion,
wits do W work.and We swn316 3 0 0 3 9 . 0 0
Ply and Prefccsinns Code:The Conlaaoe.Lice.law does nos W an.1 or Required Inspections
property who builds or improves thereon,and who does such work himself or Nmugh his
own employers.pmvided that such improvements are not intended oroRered for We.It.
however,We Wilding or improvement is sold within one year of completion,We owner
builder will have Nc burden of proving Nat he did not Wild or improve for purpose of
ssle.).
Co I.as owner of c,propemy,am exclusively contracting with licensed mnuumrs to
konsa La d proles,ply]014,Business and Professions Ws Cade:)Toe.thencor's d L J t r_
ttnselawdoesr sof uch yloan owneron=,ogy who Wilda Pumn,in We Ccmnn,and.
whocontractsLacts for such projects with a conaruaor(s)licensed phvsuam m We CanOrutoh
Ciccone Law.
❑1 am excmpl under Sec. .B&P>C for Nis
111111mal - Date3
ORKER' C MPENSATION DECLARATION f� n )1 IJ fI G r ,1 l�
Ihertb a0irtn under pcmlty or perjury arc of the fallowing declarations: f� ! 11'1' \.
❑I ham and will maintain a Certificate ofCtutsent m self-insum for Worker Compete U � L '�U❑N 4
sarion,a provided for by Section 3700 of We labor Cade,for We performance of We
work for which his Permit is issued.
❑I have and will maintain Worker's Compensation Insumnm,as m,,uimd by xctinn
3700 of We Labor Cods,for We pcmorinamo.of We work for which Is peon i0 is issued.
My Worker's Comparsadon Insurance artier and Policy number art:
Card,,: Policy No.: _
CERTIFICATE OF EKEb1P lON FROM WORKERS'
COMPENSATION INSURANCE
(This section need not W completed if the fermi,is Toone hundred dollars(5100)
or less)
I certify,that in We Performance of We work for which this Permit is issued,I shall not
employ any person in any mann esngs'mhccymmvsnbiccno the WorkeOi Compcnsaton
lawsofcmifornaAa• ' 'J F-K("
APPlicaA' r7/]�—
N0T10ETO APP CAM: ter making this Cenifmam of Exemption,you should
ocom<subject c Work om. sion provisions o(Wc labor Code,you must
.JO foMwM comply with such provisions or Wis Permit shall be deemW moked. ,
z " CONSTRUCnON LENDING AGENCY
'[~+� Ihemhy affirm Was Were iso mtavuctinn lending agemY for We perfunnancc of
C the work for which Wil permit is issued(Sec.3093,Civ.C.)
1Q Lender's Name
Z Lenders Add.
V O I ttm y that I have read Nis application and Wife that We mauve information is
�f^ coma,l agree to comply with all city and county ordinances and some laws mlatingto
Q(J Wilding construction,and hereby auWodm mpremnutiroe of Wis City to Cnmr Upon We
move-mentioned property for inspection Purposes.
H y (We)ag¢e 70 save,indemnify end keep formless the City of Cupertino against
fq liabilities.judlments,coma and expenses which may in any way accrue against said City
U Z in conxqucncc of We granting Of Wis permit
w-h APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT Issued by: Date
SOURCE REGgLgIONS. /
Re-roofs
Signature a( Plican o t r Dem
HAZ RD USMATERIALS DISCLOSURE Type of Roof
Will We Applicant hum Wilding occupant atom or handle hazardous material
as defined by We Cupertino Municipal Code.Chapter 9.12.and We Health and Safety
C.Section25532(a)?
0y. XNn All roofs shall be inspected prior to any roofing material being installed.
Will the applicant or future building Occupant use equipment or devices which If a roof is installed without first obtaining an inspection,I agree to remove
emit ha'urdnus air contaminants As defined by We Bay Area Air Quality Management all new materials for inspection.
Dis rico? ���///
❑Yes UfNii
I have mad We hazads`romaterials requirements under Chapmrfi.95 ofthe Czlifor.
ma Health 6 Safety Code,xmiaa25505.25533 and 25534.1 understand Wa,ifNe Wilding
docs no,currchily have a mesa.War h is my responsibility to rmu ly We scup.,Of We
myairemcnts wh�h th mP the pdProiasaameofa Ccdfamor ampanry. Signature of Applicant Date
owner m mo fixed agent 3 Dam All roof coverings to be Class"B" or better