05020024 CITY OF CUPERTINO
BUILDING DIV
IBIDN PERMIT '�ICUTRLG !R'INFORMATION
BUILDING ADDRESS: PERMIT NO.
KSYC CONST 05020024
ER'S NAME: - PERMIT ISSUE DATE
P UNE: SANITARY 2 iftOL NO,
ARCHnECT GINEER: BUILDING PERMIT IWO
BLDG ELECTO QPLUMB MECH
O
LOZp LICENSED CONTRACTOR'S DECLARATION Job Description
z i bunchy aflkm that 1 am licensed under pmvWom of Chapter 9(commencing
a� with Section 7")orDivimr,3o1 BuM.and Pralesstons Code.and my lk,nmis
in full force and MIIML -y/106f'
Lkenac Class Lk.g `r f`7 ADD 560 ' [-(MSS BED/,KTTCH'EN) /REMODEL
Dam GomreClar c
ARCHITECT'S DECLARATION L �j 'il� 4.L1,-.t- '
1 undcrwnJ my glom shall bu used an public records —
O /Licensed Prtcsatonel �/ A tt•�
OWNER-BUILDER R DECe Contractors
ON 7 /!
i 1 jemmy e(Rrm on I em eumpt form Jove ComnalCo License law for thy
O O following noon.(Section IID 1.5,Business and Pm@esiom Cock:My city or wnty qq
$ which mamma a permit to construct,alter.bnprove,demolish,or¢pair any suuelum �)�+f� ); "j Y s. U,�
26
�' prior an its issuance,also requires the applicant forsuch permit to Ole a signed Momentp,
�< wt he u licensed pammant m tie provisions of the Contractor's U..law(Chapt.9 Sq+Ff.:Floor Area, �� +-1>\�) � ValAt 6jo4n
$ (commencing with Section 7")of Division 3 of the Buuneumd Prefsedom Cods)m
Jut haen tempt thmefrom and the beth for that alleged cammpdon.My violation of
Section 7031.5 by any applicant for a permit subjects the applicant in a civil penalty of
not am than Bae hundred dollars($SM. 3 2`11U*n_ 4er0 0 Occupancy Type
❑I.n w rofJ pmpenymmyemployceswiMmguutheuwlecwpe m,
will do de,work•and theawctum Isnot imended oraffemd formle(Sec.70u,Busima.
and Profusion.Code:The Commetofs Limine Law dom sal apply m an morn or Required Inspections
property who bWlds or improves thereon.and who dauuch work him.eu f or though his
awn employees.provided that such improvements an notlnumded warrantor formic.If.
however.the building or imp ommem Is sold within ane year ofcompletion,the owner.
builder will have Jae burden of paving Jut he did nm Wild or improve for purpose of
ole.).
❑1,m owner of one property,am uclutively Commedng with Ilamed contncmn to
construct the pmjeci(Sec.7044,Business and Professions Code:)The Commuter's LL
cense law does not apply in an awmmr of progeny who builds or improv them n.and,
who contact,for such projects with aconuacmr(p Ilceued p000nra to the Canuactofs
License Law,
0 1 am esempt underSec. .B k P C forthistenon
er Dam
WORKER'S COMPENSATION DECLARATION
\ Ihereby affirm under penalty of perjury ane of Jct fallowing declautiom:
❑Ih.ve end Mll mainulne Cutifiesm afComentteulf-loom fa Worker's Gargan-
nation,m provided for by SeNan 3700 of duc labor Cade,for the performance of the
work fm which this permit is usual.
❑1 room and will maintain Worker's Compensation Iran==,as moaned by Section
3700 of the Labor Codes fn the performance of Jc work for which this permit Is issued
My Workefs Compensation Insurance carrier and Polity number am:
Cartier .S7l�.'G Polity Na.:
CEITfIFICA OFEKEM7TIONFROM WORKERS'
COMPENSATION INSURANCE
(Dtmaectim used not bu completed train,perm is foram,hundred dollars(Slip)
or less)
1 certify that In the performer W the work for which Iii.permit is Inued,l shall nm
employ any person in any manners as m became abject to the WorkersCompensation
Laws of California Dau
Applicant
NOTICE TO APPLICANT:If,after making this CeniBcase of Exemption,you should
OZcomIn
e subject the Worker'.Compensation provisions of the Labor Code,you most
beforthwith comply with such provisions or this permit shall bu accrued mwkcd. -
.ZwrA CONSTRUCTION LENDING AGENCY
F" Ihereby allies drum then in a contrctim Lending starlet,for Om perrmmanx,of
IX?. the work for which this permit B Wad(Sec.3097,Co.C.)
MW Q Undoes Nur:
r7. zUnder'sAddmu
U Q 1 certify,Jul I hew mess this application and mm that the above inforn adun u '
V,r! correct 1 agree u comply with all city and county mtlinamea and sum laws muting in
p SV': building connection,and hemby mthodm mpmleatUt of thin city m Cour upon ft
W abuve-mW 4s progeny for impaction puewxa
(Wju S me te tome indemnify and hick may
in m the City of Cupertino against
q Rahinsmitassc or MancoNand expenses which mryin anY wYsttmc Ratmt mid City
V 7 A PLIC NT or Man Rgrarming STANmthis permit.
rte• APPLICANT UUNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT Issued by: Date
SOURCE E GLATI
Re-roofs
Signuu o pplicmVCon racer Data
HAZARDOUS MATERIALS DISCLOSURE Type of Roof
Will tho applicant or for=building Occupant tom or handle ham£dous material '
as deBmd by Jc Cupertino Municipal Cade.Chapter 9.12.and tis Health and Safety
.Section 255320)1 ���mmm All roofs shall be inspected prior to any roofing material being installed.
to ❑Yes K Na
_ Will the applicant or fumm building occupant use equipment or devices which If a roof is installed without first obtaining an inspection,I agree to remove
emit m amms car contaminants as dcOrcd by time Bay Ama Air Quality Management all new materials for inspection.
District?
❑Yue .16KIo
I have mad the meadous.=flat,requirements..do,Chapter 6.95afthe Califon f
nia Health 6 Safety Cade,Sections 25505,25533 uW 23534.1 understand this if the building �, ( Q
dam rot cumm�dy h))re•mnanl that it k my mspomibility W notify the occupant of are
mquimmcntswhi (moth at Prior GOsmaceoraCanlOcato r sugars . Signa re of Applicant Date
owmrureu ndag , Dow All roof coverings to be Class"B"or better