05040038 CITY OF CUPERTINO w .,,tri x"3 as�Yt° •a
BUILDING DIVISION PERMIT CONRACTOR INF,ORMATION,•,*
BUILDING ADDRESS: PERMIT NOO 5040038
OWNER'S NAME: PERMIT ISSUE DATE
E:
SANITARYO. C OL NO.
ARCHITECT'/ENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
uOcc LICENSED CONTRACTOR'S DECLARATION
F❑ I bercby affirm that I am licensed under pmvisimil of Chapter 9(commencing ,Job Description
tW with Section 7IXM))of Division Sof the Business and Profwioms Code,and my limmal is r t D hr
a in fun force and effect. i 1
5�E License Class Lic.I INTERIOR REMODEL/BATHROOM/CLOSETS
,,=e, Date Comrzo "—'—
ARCHITECT'S DECLARATION
�i e I undersand my plans shall be used u public records
o f 2� 2�u5
0G Licensed Professional iO� OWNER-BUILDER DECLARATION \ ,
i1 hereby.!flim that I am exempt from the Comaaur's License Law for thes � '+
O O following moon.(Section 7131.5,Business and Proposed.Cade:Any city or county t l 11
y$ which¢quire is permit to cnnstmct,alar,improve,demolvh,ar repair any s mems
prior to is issuance,also build.the ti,linm for such permit to fit.signed sutemem
< that W is licensed pursuant to she provisions of the Conuacwr's IAcnsc law(Cbapmr 9 Sq.Ft. Floor Area Va ua[IOn
FFG (commencing with Section 7000)of Division 3 of NC Business and Proressions Code)or
to $ that he is eumpt domfrom and the butt for the alleged exemption.Any violation of
Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of 3 perp p Occupancy Type
not more than fw handled dollars($500).
❑1,as owner of the pmpeny,or my employers with wages as their sole compensation,
will do dw work and the suction,is not intended or offered fattish,(Sec.7011.Business
and Pmfessimu Code:The Comraztor`s License law does not appy In an"am of Required Inspections
property who builds or improves thcmon,and who dock such work himself or through his
own employers,provided that such improvements art not intended or offered for ale.if,
however,the building or improvement is sold within one year or completion,the owner-
builder will have the burden of proving that he did not Wild or improve for purpose of
ale.).
❑1,as owner of the propeny,am exclusively contracting with licensed convectors to
construct the project(Sec.Triad.Business and Professions Code:)The Contralto's Li-
rue taw does not apply in an owner of property who Wilds or improves then,om,and
who contracts for such projects with aconaaetor(s)licensed l ura n m w the Cantractek
License law.
❑ lam exempt and//9�5/}e� B&PC)for this t an
Owner //If l l t / Date / /�J
V O�COMPENSATION DECLARATION
1 bareby affum under penahy of perjury arc of the following declarations:
sand will maintain a Ceniflcam of Consent to self insure for WohcrsCompen-
a,as provided for by Section 3700 of the labor Code.for Ne performance of Ne
work for which this permit is issued.
❑I have and will maintain Worker's Compensation Insurance,u acquired by Section
3700 of the labor Code.for ds pedrormance of the work for which this permit is issued.
My WorkcYs Compensation Insurance canner and Poliq number am:
Caner. Policy No.: _
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(Thu section need not W completed if IK permit Is foronc hundred dollars(S Ion)
or Imus.)
I certify Nat in ds pe form m.of the work for which this permit is issued.I shall nut
employ any personin any manner snutMcomS wbjc` w the Worked Compensation
LawsofCalifomia.Dare d/n /n✓ NnaA/w/1�.N
Applicant
NOTICE TO APPLICANT:If,after making this Ce Beate of Exemption,you should
become subject to to Worker's Compensation previsions of the labor Code,you must
.,O forthwith comply wit such provisions of this permit shall W deemed revoked.
Z"-' CONSTRUCTION LENDING AGENCY
[r N. TWn,by affirm that thea is a construction lending agency lot the Performance of
ai 7 Ne work fur which this permit is issued(Sec.3097,Civ.C.)
n,1 0 Lender's Name
5 Z Lender's Add.
U Q I certify that 1 haw mad this application and sum that the above information is
D.^F coned.!agree to comply wish all city and county ordinances and stall laws slating w
0U Wilding counteraction.and hereby radiation mpreunutieas of this city to closer upon tW
r W ahom-mentioned pmpcny for inspection purposes
r G (We)agree wave,indemnify and keep harmless the City of Cuycnino against
rn liabilities,judgments,costs and expenses which may in any way same against said City
U z in consequence of the granting or this permit.
'-' APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT Issued by: Date
SOURCE REGULAATI�gi$v1.,g'_pr
- - - I +I.y�gy�
/Aff///N/Y 1YIsfx/YaL/ /1./1V/v ` 4 Re-roofs
Signawmof Appli UCcolommr Date
HAZARDOUS MATERIALS DISCLOSURE Type Of Roof
Will the applicant or future building occupant store or handle hazardous material
as defined by the Cupertino Municipal Code.Chapter 9.12.and the Health and Safety
Code.Section 25532(a)?
[3y. 14 No All roofs shall be inspected prior to any roofing material being installed.
Will the applicant Orfuwle Wilding Occupant usequipment ordcvimswhich If a roof is installed without first obtaining an inspection,I agree to remove.
ha"mous air conaminana as defmcd by the Bay Area Air Quality Management all new materials for inspection.
rill?
C]Yes Nu
1 have mal the bmarthms materials requirements under Chapter 6.95 of Ne Caliror.
riaHealth&SafmyCode.Sectiuu 155115.25533 and 25531.I underearw Nm ifthe Wilding
dors not currently haw a mom,Nat it u my responsibility m door,tW oec.,am or she
requismcnka whit atprn'or i u an cmrlc2"0rgfcaypgy�� Signature of Applicant Date
Owner or authoriz.cJ agent
T/ /Date All roof coverings to be Class"B"or better
L