04030154 CITY OF CUPERTINO h
BUILDING DIVISION PERMIT r CONTRACTOR INk'QRMATION °-
-Npffi,. Or .a=5,x rs
BUIL DING ADDRESS: GIANT CONSTRUCTION PERMIT"D04030154
EW NAME: PERMIT ISSUE DATE
J ,SIMON
NE: SANITARY N0. CONTROL NO.
7—
ARCHIT[CTIENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
�Oa LICENSED CONTRACTOR'S DECLARATION lob Description
`-U C I hereby alrm that I am licanxed under provisions of Chapter 9(commencing P
^mai with Section lUflO)of DiviaionJof dac Bualrcssand Psofcsdona Code.and myliccnsc is
y infallfoleeandelfeck SFDWL-2 STORY LIVING 3390
jawj? Date Class Connector
A
;_o Dam C'S DELL GARAGE 601 SQ FT VA`/_
WWy ARCHITECTS DECLARATION
0-< IundarstanJ my planxxhall be usW as public rtcnrds
DyU
C G Licensed Pmfcssional
5 OWNER-BUILDER DECLARATION
.�M I hereby,(Sere than 1 I exempt from the Contractor'sCm License law for the
❑O which following uires a.Permit
t 9(131.5.construct.alteu and ve de oli h.or Any oily lir roomy
x m which reyuirp a penman be orsthalter,improve for such
demolish,lir repair any structustatement
poor to incensed pursuant
to the the applicant for Contractor's
ontra Permit to Lmcaaignedauimmcm
< Ruthe if me .lamed pursuant to the Xh of Division
of the e8 usicmr'and proflaw(Chaplv9 Sq.Ft. Floor Area ValIIat100
1— (commencing(coms,is exempt Secfrion and
Divisiom3 of theeged exe and profession;Anyona Coda)of
Nm Is,u 31.5 b any applicant
p li and or basis for be alleged exemption.Any l:moon of 0000
not mom
oIDanlive airyreddanars($5ermit subjects the applicanno,cavil pcnehy of APN Number �Occ ancy Type
not mort than Rue hundred dollars(5500), s�s�
❑L as owner of the preperty,ormy employees with wages as dow sole compementlon. ��47Fw.T'$
will do Nework and do imm n e is not intended a offered rorsel4(Sec.71244,Businw tt;;A
and Professions Code:The Contractors License law dors ret apply m an owner of Required Inspections
property who builds orimpfous Herron,and whodoessuch work himself or through his ``'mow•
own employers,provided Nal such improvements meant intended or.nand for sale.If,
however,the building or improvement is mid within one war of completion,the owner.
builder will have the burden of proving that M did not build or improve for purpose of
k.).
K as owner of the propsny,am exclusively contracting with licensed comoacmn to
-met the project(see 71N4.Business and Professions Code:)The Contractor's Li.
come Law does not apply to an owner of propcny who Guilds or improves daemon,and
who contracts for such projects with a conuacmr(s)licensed pursuant o the Cnnuactors
na Law.
arreac pt oder Sec. B&P/C/�for dila reason
act
Data
WORK of S COMP NSA T ON DECLA ITIIN
hereby allinn u penalty of perjury ane of the following dalaretion
I have ate will maintain a Certificate of eonscm to self-insure for Workerscomper-
cation,as provided for by Section 3700 of the labor Code.for the performance of dm '
work for which this permit is issued. G
1 have and will maintain Worker's Compensation Insurance,as moored by Section I r✓J
3700 of dac labor Coda,for the perfornanee of the work for which this permit is issued.
My Workers ComPcruation Insurance(artier and Policy number rum:
Cartier. Policy No.:
CERTIFICATE OF EXEMPTION FROM WORKERS' I
COMPENSATION INSURANCE L .
(This section need not be compkOsJ if the Permit is forme hundred dollars(Ilia)) _
or less.)
1 certify mat in the performance of the work for which this permit is issued.I shall not
employ any person in any manner so as in become Subject o the Workers Compensation
Laws of California.Date
Applicant
NOTICE TO APPLICANT:IL after making this Cenificale of Exemption,you should
become subject in the workers Compensation previsions of the labor Code,you mint
.J O forthwith comply with such prnviesom or this Permit mall M deemed minted.
Z`-'
CONSTRUCTION LENDING AGENCY
[r .�.. l hereby affirm that there is a conswctinn lending agency for the performance of
Oa. d c work fur which this permit is issued(Sce.31297,Civ.C.)
til A Lender's Name
,z Lender:Add.
U 0 I certify thn 1 have mad this application and state dart the about information is
Fcorrect.I agree to comply with all city and county oNinances and suite laws relating to
DU building construction,and hereby authorize representatives of this city to enter upon the
ra above-mentioned pmpcny for inspection purposes.
(We-)agree to save,indemnify slid keep harmless the City of Cupertino against
fn liabili1, of mcnn.cosu and expenses whichmayinanywaya<crocagainstiewi City
Uz in conseq cc free granting of Nispcnni1. /
APPLICANT NDERSTANDS AND WILL COMPLY WITH ALL NO -PO NT Issued by: Da[A
50VV T.
EK
CATIONS, n
Re-roofs
ig lurepplieanV tot ate
H DOGS MATERIALS DISCLOSURE Type of Roof
4j1dWill the applino r fmure building Occupant more or handle hazardous masnal
recd by the Cupertino Municipal Code.Chapter 9.1],and the Health and Safety
c,Sccmn25532(g7 • All roofs shall be inspected prior to an roofing material beim
❑yes es'. P P Y g g installed.
Will the applicant or future building occupant use aquipment or devices which If a roof is installed without first obtaining an inspection,I agree to remove
nil harardo.air conumimanu as tkhncd by the Bay Am.Air costly Man igcmenl all new materials for inspection.
Ld.
❑Yes NuI have mal the hvardnus materials requirements mukrChapter 6.95 ofthe Califor-
lm&SafctyCodc,Satires,25505,25533 and25534.1umdarstare that if building
ot a dy have a Osman.dace it u in sponsibii ty m notilydo accts ant Jct
mea hin..Woelpnormiss cof.cconrcina. cppyiyry Signature of Applicant Date
r p pnzedagent V �teJ All roof coverings to be Class"B"or better