05020164 CITY OF CUPERTINO
BUILDING DIVISION PERMIT C0NTRACTORINFl1RhIATION b
BUILDING ADDRESS: PERMIT NO.
05020164
OWNER'S NAME: PERMIT ISSUE DATE
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AT MMMANARAN SANITARYqg� OL NO.
1AARCHITECTfENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
40LICENSED CONTRACTOR'S DECLARATION Job Descri tion1 Wrcby affirm Oat I am littnud under provisions of Chapter 9(commencing P ction7")ufDivision 3ord¢Busineuand PmfeWianKode.and my lactose isro eanderr«tDEMO (E) HOUSE
D� e Class Lie.Jr
ZFn Dam Contractor nor
or ARCHITECTS DECLARATION
1 understand my Plain shall W used u public rxnrds
JyU �
N Licensed Professional
OWNER-BUILDER DECLARATION
a� 1 hereby affirm Oat I am exempt from the Contractors Limnse law for the a _ - /L
ip O following mason.(Section 7031.5,Business and Pmfessiom Code:Any city or county
K m which requires a permit to consumer,alter.improve,demolish,or minor any stmetum
Is
prior to its unuamc,also sequins the applicantfor such permit to File a signed statement
Oat he is littnmd Internet o due Provisions Of duo Contractor's Uscmc Low(Chapet 9 Sq.Ft. Floor Area Valua on
ter$ (commencing with Section 7")of Division 3 M the B usineas and Pru@ssions Codo)or
Oat he u exempt therefrom and Oe bine for the alleged exemption.Any violation of
Section 7031.5 by cry applicant for•permit subjects the applicant to a civil penalty of 3 2V. b1TRtter0 0 Occupancy Type
not mole than five hundred della.(S5W).
1,as owner of Oe ProPmY•or my cmployccx with wages u their role compenmdon.
will Pr Ocwo s Code:dthmumem.ls rhes Loose Lac dos not apply to in,owner.. Re uired Ins ections
and Professions ldsoThe Comnnora License Law dors not apply to an owner is q P
Own enywho builds oimproves thereon,and who does such work in offered
for We his
ownemployees,ping or
pr such improvements arenot immndWumon.red far owner.
builder.the building or improvementg mid within one Wild
of completion,the Fop.of
Wo.).r will neve the burden of proving Oat W tlitl not Wild or improve for puryosc of
Wo.).
❑h as mvnes of Oc pmpcny,am esclusively contraning with licensed contractors to
eommic,the project(Sea 9844,Business and Rofrssions Cade:)The Crue sacmr's Li-
cense law docs not apply m an owner of property who Wilds or improves Demon,and
who contracts for such pmlcm with a mourector(a)licensed pursuant to the Connors
License law.
Q l am eeeJmpt under Sec. ,B&P C for this..On
1370MI,
�WORKER'SCOMPENSA NDECLARATION
1 hereby affirm under Penalty of perjury one of the following declarations:
have and will maintain a Cerufcam of Consent w self-onium for Worksrs Comen-
n,as provided for by S ,oro 370 of the labor Co..far the peff.momm of the
far which this permit is issued.
have and will maintain Worker's Compensation Inurance,as required by Section
of Oc Labor CO .for the perfotman.ofOe work for which this permit is issued.
orkers Compensation Insurance canter and Policy number am:
ier. Policy Nm.: '
CERTIFICATE OF EXEMPTION FROM WORKERS' '
COMPENSATION INSURANCE
(Thu scours need not hecomPleed if the Permit is fm One hundred dollars(Safi)
ter less)
1 certify Out in Oc iterrooranec of the work for which this Permit is issued.I mail not
employ any penin many in=Mr Wem.A b Cetmdle Wiftn L'empenWden
Laws of Ca]I mia. am_a
Applicant //hh rY n,....., t
NOTICE O APPLICANT.If,after mad hYis Lrinflum of Eacmpumn,you Onu1J
h.eome iorm,in tho Worker's cmexi aim provisions of ted Union,Code,you must
.J O foMwith comply with such provisions or this Permit shall he deemed revoked.
Z� CONSTRUCTION LENDING AGENCY
[+ I hereby affirm Oat den is a construction lending agency for de p.rformamre of
D5 the work Tor which this permit is issued(Sec.309),Civ,C.)
111 Q Lender's Name
G lender's Address
U Q 1 certify Oat 1 have mad this application and state Oat Oc above information is
I2. F come,.1 agree to comply with all city and county Ordinances and sum laws mlatint to
OU Wilding construction,and hereby audiumne repreRnuati`ts or this city to enter upon the
r W above-memiuned poiNny for inspection purposes.
pw (We)agree to save,indemnify and keep harmless the City of Cupertino against
F" col liabilities judgments.costs and expenses which may in any way accrue against mid City
U Z to mosequeme of Oc granting of this Permit.
^ APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT Issued by: Date
SOURCE REGy�3}�..ATl99��S. / l
.fOctX6f.unA,.�,(n 41"105- Re-roofs
Signature of ApplicamlComfacter T
HAZARDOUS MATERIALS DISCLOSURE Type of Roof
Will the applicant or future building occupant store or handle ha.Nous material
as defined by Bx Cupenim Municipal Code.Chapter 9.13;and the Hcahh and Safety
emdc.Sttuon 35532(a)) All roofs shall be inspected prior to any roofing material being installed.
❑Yrs 'oI NO
Will the andicansorJfututure Wilding occupant use equipment or devices which If a roof is installed without first obtaining an inspection,I agree to remove
I harardous air contaminants as defined by the Bay Area Air Quality Management all new materials for inspection.
trier?
❑Yes XNu
1 have mad the hanidous materials requirements under Chma,r6.95 of the Califmr
ni.H.ldb&Safety Cede,Socuoos 255(15.25533 and 25534.1 undenda d Ouirde Wilding
Joos not currently have a temol Nat it ne my mmmssibility m notify ted occupmt of the
mgaim rota mmm9¢tWmet rimrtmimpmaer.c.rtieeatemracupancy. Signature of Applicant Date
Owner or amnmrived.pen, I D,mb All roof coverings to be Class"B" or better