04090042 CITY OF CUPERTINO - fix' a 4,,-
BUILDING DIVISION PERMIT CONTRACTORINFORMATION" ' - - - .-
qx :,•::m ,nr%u+-tv 7 sb. $ k cWs^
BUILDING ADDRESS: PERMIT No 04090042
OWNER'S NAME: PERMIT ISSUE DATE
RAZA FO
ME: SANITARY NO. CONTROL NO.
ARCHITEC(ENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
O O O O
y00 LICENSED CONTRACTOR'S DECLARATION
F 1 hereby affirm that 1 am Licensed under provisions of Chapter 9(commencing Job Description
;gycalm Section] )or D' slop 3 oflM B>s IuAand Professin.Code.mul my list.is
m infull( rad cRcc ✓
,.�z L1ee. a r D Llc.g 450477 TENANT IMPROVEMENT-LAB
c.nuamr _ INSTALL 6000 WM & BRANCH CONDUIT
ARCHI'IECI'S�ATION
�i -a nderstand my plans shall Mused as puh is records
eau
3 u F
Licensed Professional
�0� OWNER-BUILDER DECLARATION
I hereby affirm that 1 ore exempt from 0.C.nwmor's Lt...Law for the
K o a following reason.(Section 7031.5.Bulinus and Profeamons Calc:Any city or county
m which requires a Permit to conswct,alter,improve.demolish.m repair any strucun,
prior to its issuance.also requires sM applicant forauch permit m file a signed sulemerit
that he is licensed pursuammthe provisions of lM Comncturi License Law(Chapter 9 Sq. Ft.Floor Area Valu t'
ne I-Q (commencing with Station](100)of Division 3 of she
Business and Professions Code)or Y
that he is ea mpt therefrom and 1M baso to,the alleged aemption.Any violation of
Section 7031.5 by any applicant for it permit subjects the applicant l...wil penally of APN Number Occupancy Type
Out mom man fiK hundred dmlam(1500). 31609030 . 00
I,u owner of the prepcny,or my employcu wire cages as 1Mir sole compenution,
will do the work and the auction,is not intended or offered forsal.(Sec.7014,Business
and Profession.Code:The connector's Licenselaw does nus apply 1s,an owns,of Required Inspections
prepeny who Wilds or improves therc.n.md whod.essuch.,it himself.,through his
own employees,provided that such improvements are not intended or offered for sale IL
however.the building or improvement is sold within one year of completion,out owner. 4
Wilder will have tM W,d.of proving that he did not Wild or improve for Purpose of
sale.).
El I,to owner of the property am emusively contracting with licensed contractors to .J-
conswn the project(Sec.7144.Business and Professions Code:)TM Contracrori Li.
cense law does not apply to an owner of preperty who Wilds or improve;thereon,and tJ�
who contracts for such projects with a conucmr(s)licensed pursmnno the C.ntracthr'a
License law.
1 are uempt under Sec. .B A P C for this season
Owner Data
WORKER'S COMPENSATION DECLARATION
1 hereby affirm under penalty of perjury ane of the following declarations:
,J 1 haus and will maintain a Cenifieate of Consent to self-insure for Workers Compere
sation•as provided for by Section 3700 of the Labor Code,for the performance of she
week for which this permit is issued.
❑1 have and will maintain Worker's Compe.auo t movants,as required by Section
37W of she labor Code,for she performance of the work for which this Permit is ls;uetl.
My Worker's Compensation Insurance career and Policy number are:
t'"9o�/n-CdW&W rIPolicyrte+ 'a19094413
CERTIFICATE OF EXEM MONWORKEI�10'F1 RS'
COMPENSATION INSURANCE
mbin section need not Mcornplmod if 1M pewit is(in onchundred dollm(SIM)
or less)
1 cattily that in the Performance.f the work for which this Permit is issued,l shall not
employ any person in any manner an as to become subject to we Worlaw'Compt.ation
Laws of California.Dau
Applicant
NOTICE TO APPLICANT:If,after making this Cenifleate of Eaemplion,you should
become subject in the Worter's C.mpc.adon previsions of One tabor Code,you most
,J 0 hthis forthwith comply with such previsions or s permit shall be deemed revoked.
Z" CONSTRUCTION LENDING AGENCY
I hereby arm that then is a construction lending agency for she performance of
�i the work for which this Permit is iuued(Sec.3097,Civ.C.)
GLender's Name
z lender's Address
U Q I cenify that I have read this application and some mat me above information is
Lc.P coma 1 agree to comply with all city and county on irwcea and sale laws relating to
0U building cooswcom,and hereby euNona upresemuties of this city tomo,upon the
r Wabove-mentioned property for inspection purpoxs.
CL (WO)agree m save,indemnify and kap harmless the City of Cupertino against
H liabilitiet,judgrimms.case and canc.which may in any way accrue against said City
U Z in consequence of the got t of this permit.
PPLI S DS AND WILL COMPLY WITH ALL NON-POINT Issued by: Date
U E REG TIO `�
V Re-roofs
am plicar Contrumr Date
HAZARDOUS MATERIALS DISCLOSURE Type of Roof
Will the applicant or future Wilding occupant stere or handle hanrdous material
az defined by the Cupertino Municipal Cod,Chapter 9.12,and the Health and Safety
Code.Scm.n 25532(a)7 6� All roofs shall be inspected prior to any roofing material being installed.
Ye
Will mea applicant or future building ac.ant use equipment or&vices which If a roof is installed without first obtaining an inspection,I agree to remove
Pp C P Area
n
.mit Mrardnus air contaminants u defined by me Bay Arca Air Quality Management all new materials for inspection.
Distric4 —!
❑Yes k�u
I have maJ the hare dour materials reyuirtmenu under Chapter 6.95 of the Caliror"
no Health&SaR1YG c,Sad.na25505,25533 and 25534.1 undemund that if lM Wilding
dues L the it u my remo.ibdOy u notify the acupanl of the
reqs nmw at etpd.r wamOr.Cmtiream Signature of Applicant Date
Gwn a. ,ludas=rat Dale All roof coverings to be Class•'B" or better