05020026 CITY OF CUPERTINO
BUILDING DIVISION PERMIT .CONTRACTORINPQRMATION „
I bA =S@Th_ avGm4d *Gv-,g a* .x4�8mCYfi ` '
BUILDINGADDRESS: """'05020026
NER'S NAME: PERMIT LSei DATE
.JNE: SANITARY N0. CONTROL NO.
ARCHITEC tENGTNEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
0 0 0 0
u 0 0 LIC CONTRACTORS DECLARATION
I hereby affirm Hot Nat I amam licensed he Bu under and
Piofers of Chapter 9(commencing Job Description
with Section 7")dof ec Division J of the Businessand Prufessiam Code,and my license is
wlmrteanaerr«t. TI--DENTAL OFFICE
j = License Clan Lic.0
Dam centrief r
F rJ` ARCHITECT'S DECLARATION
m I undcrsund my plans shall he used u public memods
JyU
30� Licensed Pmfcammal t
3 - OWNER-BUILDER DECLARATION
<f 1 hereby aBirm_thm IM escmpt form Ne Control License Law for the
p o following meson.(Sects ]031.5,Business and Professions Code:Any city or coon,,
wm which reputes a permit to ennoruct,aper,improve,demolixh.or repair any structure
s-Raprior m its issuance.also requires the applicant for such Permit file a signed statement
that he is licensed pursuant m the provisions of the Conuactur's License Law(Chapter 9 Sq. Ft. Floor Area Valuation
¢tea (commencing with Section7MO of Division 3 of the Business and Professions Code)or
- that M it exempt therefrom and the Batu for the alleged assumption.Any violation of
Salon 7031.5 by any applicant for a Permit subjects the applicant to a civil penalty of 3 494RUIfbe10 0 Occupancy Type
not mart Nn five hundred dollars(M).
p y yp
❑1,u owner of the Property,or my employees with wage as licit sal,compensation. 42
will doth,work.endo: he cturcCommittees
noes Licded ense
a[Rmdwdo fs.1 apply 7(144,Business
and Profusions Code:The Con isnoti Litten Law docs ort appy men owner of Required Inspections
properly who buildsarimproves thereon,and who donation work himself or through his
n employee,provided that such improvements ere nut intended or offered for We.IT. /
however.the building or imprevsment is sold within one year of completion.the owner-
builder will have the burden of moving Nat rte did not build m improve for purpose of
sale.).
El I,as owner of the property,am,xclmiv,ly convecting with licensed antsumrs to .�
construct tae projea(Sec.7064,Business and Por@stieru Code:)The Comrscmri Li-
cense,Law does not apply in an owner of property who builds or improves thereon.and V
who contracts for such projeeta with a eonvaetor(s)licensed pursuant m the ConVaelora
Lie Law.
I ache /
❑ rum exempt tarda Sec. B&P C far this rtasaA
net Dam-2.--j—dS
WORKEft COMPENSATION DECLARATION
I hereby mine under penalty of perjury,one of the following declarations:
1 ham and will maintain a Ccrtifnm of Consent to Wf-imare for WorkeYaCompen-
Wom,as,provided for by Section 3700 of the labor Code,for,the perfmmaram of the
work for which this permit is issued.
❑1 have and will maintain Worker's Compensation Imuran¢,as required by section
3700 of the labor Code,for the performance affirm work for which Nis Permit is issued.
My Workers Compensation Insurance caroler and Policy number art:
Cannot. Policy No.:
CERTIFICATE OF EXEMPTON FROM WORKERS'
COMPENSATION INSURANCE
men section reed not beeomplemd if the Permit V forom hundred dollars(SIM)
or less)
I comfy that in the perfomnenec of the work for which this Permit of issued.I shall not
employ any pmmn in any manner m u w become subjectto the,Workers Compemation
LawsofC a.Date
Applicant A :;;at '—O S
NOTICEA PL'ICAN T:IL dr making this Ccnincem of Excmptian,you should
become subject to the Worker's Compensation previsions of the labor Code,you must
.J Z forthwith comply with such provisions or this Perna tshall he deemed revoked.
z O CONSTRUCTION LENDING AGENCY
I hereby affirm that Bert iso construcvnn kodingageney to,the Pofmmanee of
C the work for which this permit u issued(Sat.3097,Civ,C.)
IS7 Q Leminea Name
1 Lender's Address
V Q I certify that 1 have,cad this city
ncoand tam Net and
above information
ng is
0
correct.1 agree to comply with doll city and county ordinances and sum laws relating to
pU movengeotimed!construction,and boobyauthonprposesenutivcsof Niscity to enter upon the
about-(We). m to ertysaw,for Inspection an tum,ea
(We)agree t.cove,indemnify end which
marinas the City of against
against O
UZ liabilitiesunce Of ofostsand,xpeucsmay in any way accmc against said City � rZw
V z Aconsequence
PL C9ANT UNDERSTANDSospoinit,of tA'ND permit.WILL COMPLY WITH ALL NON-POINT Issued by: Date
SOURCE R�(ip�IIp�$�
( � � Z^2-- 5^ Re-roofs
Signaturbu ApplicanuVonuxtor Dam
HAZARDOUS MATERIALS DISCLOSURE Type of Roof
Will the applicant or future building Occupant store or handle hazardous material
u defined by the Cupertino Municipal Codc.Chapter 9.12,and the Health and Safety
ode.Section 25532(x)?
❑Yes ONO All roofs shall be inspected prior to any roofing material being installed.
Will the applicant or future building occupant use cquipmcm or devices which If a roof is installed without first obtaining an inspection,I agree to remove
mit harardou air contamintnts u defined by ton,Bay Area Air Quality Management all new materials for inspection.
Dia ria?
p Yes 0 N
I have mad Ne hand ms materials requirements undo(Chnuw,6.95 of the Califon.
nia Health&Safety Codc,Secdons25SM 25533 and 25534.1 undcrnsd thatif tM heilding
doll et NRently have a root,loot it h my responsibility w nodly up,.,.,.t of the
rcy^i�which mutt be ,�pp��r ismance nfa ccoirese of Occupancy. Signature of Applicant Date
R L/e�liu 2 – 2 'o S—
ow crurauthorindagent Dam All roof coverings to be Class"B"or better