05040022 CITY OF CUPERTINO z•, am t vat V' '-
BUILDING DIVISION PERMIT %%CONTRACTOR INFORMAT,I�ON
BUILDING ADDRESS: PERMIT NO.
05040022
OW NER'S NAM PERMIT ISSUE DATE
E; SANITARY KO. C OL N0.
ARCHITEC IENGINEEW BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
0 0 0 0
O o LICENSED CONTRACTOR'S DECLARATION Job Description
s F 1 ion 7 affirm Ilut 1 am licensed under provisions of Chapter 9(commencing
ia
with Semmn7lN101of Division 3ofdm Basin.reed Profession Code.and my license is
Z' in full force and effect
5y,z License ClassLic.g REVISION- -IN HOUSE USE ONLY
,gd, Dam Capt., NO NEW PERMIT ISSUED/ORIG. #04060231
ARCHITECTS DECLARATION
¢ 1 understand my plans shall he used as public meet&
�yV
3a�
Licensed Professional
3
OWNER-BUILDERmft CoATION
n f I hereby.(Rrm that 1 1. exempt from d r mesinctCo e:License taw for the
o O which
re ¢assn.(Section ND 1.5,Business and Tafeusinm Code:Any oily or county
$ which inquires a permit no meas the,alms,improve,demolish Permit t m¢silt any suuaurc
prior ser its i licensed
p also eir to ft pro applicant for such permit to ieIe singled summon
frC rhat isincing odpuuuammlMpmvivianafthe oftheB sines nittncLaw(CMpmr9 Sq.Ft. Floor Area Valuation $0
that he is
(commencingwith heeion rom and of basis
3 of al Business exempt Pomfon.Anynvi Csdc)or
.. That he u exempt therefrom and um buts for Ne alleged exemption.Any violation of
Section 7031.5 by any applicam for a permit subjects has applicant to a civil penally of APN Number Occupancy Type
not mom Nan fin hundred dollars(S500).
01,uowneraflM proprny,mmy employees with weguulMir sole compensation, 36930015 . 00
will do the work,and Ne structure is not intended oroffemd forsam(sec.7014,Business
and Professions Code:The Contractors License Law does not apply in an owner of Required Inspections
property who builds air improves thereon,and who docs such work himself or through his
own employees,provided that such improvements are not intended air aQemd for We.If.
however.the building or improvcmem is sold within enc year of campmurn.Ne owner.
builder will have the burden of proving Net he did not Wild of improve for purpose of
tile,). C-
❑h as owner of sew Sec.prapiory,704 ,B exclusivelynd convecting with licensed contractors t.
construct dm es not (Sec.]014,Business and Profusion Code:)The ConvacmrY n
echoLaw doser supply can ownerofproperry who buildsorimproses Neuron,and.
whocontracts for such projects with a contractor(s)licensed pursuant m the Conmash
0
License Law.
❑I am exempt under Se. .B k P C far this reason
Owner 1 Dam
W RK OMPE SATION DECLARATION
1 hereby affirm under Nm ty of perjury om of ft following declaauon:
hsn and will maintain a Cci ificane ofCanmm to self-insure for Worker's Compcn-
n,as provided for by Scnisn 37W of the Labor Code,for Ne performance of We
work for which this permit is issued.
1 have and will maintain Worheri Compmuation Inurance,as required by Schon
37W or Ne labor Code,four tate xrformucc of the milk for which this permit is issued.
My Workers Compensation Insurance camicr and Policy number am:
Cartier: Policy No.:
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(This section need not becumplemd if the permit is for one hundred dollars($104))
to Mss)
I unify that in to performance or the work for which this permit u issued.l shall not
employ any persenr2 annersoam M,omesubjecuoft Workers Compensation
Laws of Cali(omia.q(c/ �
Applicant �A
NOTICE TO AP IIC is f,aM�aking this Certificate or Exemption,you should
became subject to the Worker's Compcuation provisions of the Labor Cede,you must
�z roMwithcomply with each pmvisionin,thus Permit shall tic deemedremkcd.
Z O CONSTRUCTION LENDING AGENCY
[-..�. I hemby affirm Nat them is a emuuuaion lending agency for the performance of
C
the work fur which this permit is issued(Sec.AA'l,Civ.C.)
W Lenders Name
z Lender's Address
U O 1 certify that 1 ban read this application and sum that the abme information u
Iy E correct,I agree in comply with all city and county ordinamxs and sum laws relating m
O building consuvaion.and hereby authorim mpmsenritives of this city to enter upon the
r W above mentioned property for Inspection purposes.
(We)agree to on.indemnify and keep harmless the City of Cupertino against
H raj, liabilities.judgments.cors and expenses which may in any way accom against sad City
u z in eonsequencv of the graminis of this permit.
APPLICAN'TIV,NPERSTANDS AND WILL COMPLY WITH ALL NON-POINT Issued by: Date
SOURCE REG ON
A �
SignAPp a�Nl oDb ate Re-roofs
HAZARDOUS MATERIALS DISCLOSURE Type of Roof
Will the applicant or furore building occupant atae or handle havu lams material
as defined by ser Cupertino Municipal Code.Chapter 9.13,and Ne Health and Safety
code.Sseden 25532(a)7
Oyes ON. 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
t harardsus it contaminants as defined by the Bay Amo Air Quality ManagcmcM all new materials for inspection.
icrt
❑Yes 0N
1 have mad the hmardaus materials requirements under Chapmr6.95 orthe Califno-
on.Neal"Sarety Code,Secuan 155(15.15533 and 355X.I make stan0 thaifue Wilding
does note uy haw�a tenon,that itis my responsibility to notify the occupant of the
requirements me armismame.raWmOeamor cp ey Signature of Applicant Date
All roof coverings to be Class"B"or better
Owner or authi dspent Doc