04080038 CITY OF CUPER'I'INO
BUILDING DIVISION PERMIT .0 ONTRACTORJNFORMATION
BUILDING ADDRESS: PERMIT NO.
Q N CONSTRUCTION 04080038
OW NEWS NAME: PERMIT ISSUE DATE
0ARCIM
E: Nr-TJVRN 519 LISA LN SANITARY OL NO.
BUILDING PERMIT INFO
ECfIENGINEERo - DG ELECT PLUMB MECH
t�
uo0 LICENSED CONTRACTOR'SDECLARATION Job Description
z u� 1 bereby affirmNat 1 am licensed under provisions of Chapter 9(commencing
az with Senimn 7(MltB of Division Jof the Busi�s and Prmfessiuns Cade.and mylicenu is
n<s in full force and ct.
L;eeIs s Lie.0 m7 D Q D—I) REVISION--IN HOUSE USE ONLY
,;.o Dam C.m.ctor NO NEW PERMIT ISSUED ORIG. #04070160
ARCHITECTS DECLARATION
a–r Iundcasxnd Rf lhxns' Iheu d as Public records
3 6' Licensed Pmfcssional
x.a3 oat IamBUILDER DECLARATION
I hereby maxo .('Sinn Nal 1 1. exempt from Oe Contractor's License law for the
my
Xwhichfollowng reres a Perm(Secit t 7BJUnet,5. almr.sire d Pmfcvaions Code:Any cm or wary
.m. which requires a pares(hs metro.,pplic improve,demolish,or repair any wvcum
Prior m its issuance.also requires Ne apPliewl for such perms(so Ric a signed saumem
,i< Wal he is licensed pursuantto the provisions of the Contractors License Law(Chapter9 Sq. F[. Floor Area Valuation C0
`s a (commencing with Section 7000)of Division 3 of the Business and Prefessimts Code)or Y
i $
that h,is exempt Therefrom and the basis for the alleged exemption.Any violation of
Section 7071.5 by airy applicant fon pared subjects the applicant a civil penally of APN Number Occupancy Type
not roam Nan five hundred della.(S500). ttr
1,as owner of tlm property,or my employees with wage'as Nei,sole compensation. 32643055 . 00
will do the work and the structure is no,Uncoiled or offered mraem(sec.7tMa,Bosinrss Required Inspections
and Rofessions e Code:The Counacme,License Law does not apply to an owner of q P
property who builds or improves thcrcmn,and who does'uch work himself ardirough his
own employers,provided that such improvements are not intended m oRemd for sale IL
however.the building or improvement is sold within one year of completion,Ne owner-
builder will haw the burden of proving that he did not build or impmw for purport of
sale.).
R�t 1,as owner of the property,am exclusively contracting with licensed cantata.m
mama the project ISac.7041.Business cad professions Cade:)no Contranmrs Li
certse taw docs not apply in an owner of propcny who build$or improve thereon,and
who contracts for such projects widt x camracmr(a)licensed pu..art ro the C.O.i.es
License Law.
FJ I am exempt under Sce .B k PS�C for.do.�,�son
Owner Dam OT—0'
\ FR'S 'NSATION DFLLARATIOttYY ��
1 hereby affirm under pcna ty of perjury ow of the fallowing de<larnions:
ban and will mainaia a Centi0care of Consent to sett--mom for Workcrs COmPem
on,as provided for by Section 77th of the Labor Code,for We performance of the
work for which Wil panni,is issued.
I boom and will maintain Worker's Compensation Insurwce,as Sc
required by Cie.
3708 of the labor Code,for the performance of the work for which this permit is issued.
My Worker'sCompeolahm loan.—Cannot`
and Policy num her art:
Co.C'. Paliry No.:
CERTIFICATE OF EXEM MON MOM WORKERS'
COMPENSATION INSURANCE
mlis$maim recd not bccompleted if ie Fcmtil u format hundred dollars($(jel)
or real.)
I ccnify that In the paformanee of the work far which Wil Permit is issued.1 shall nm
employ any person in any mannersn as to become subject o dm Workers Compensa ton
Laws of California.Dam
Applicant
NOTICE TO APPLICANT:If,after making this Cenificale of Exemption,you should
become subject to the Wakcr a Compensation provisions Claim Labor Code.you muse
.Jz forbvitheamply with'uch provisions err Oil permit shall he deemed mv.4cd.
Z Q CONSTRUCTION LENDING AGENCY
(-. I hereby affrtm that there is a Construction lending agency for the paform.nee of
(3S 7 the work for which this permit is issued(Sec.3097,Co.C.)
IT3 Q fender's Name
z Lender's Address
V 0 1 Certify Oat 1 haw mad this application and sou Unit the anon information is
U..F carte.I ague m comply with all city and county ordinances and sum laws relating to
>iV buildingconstruction.to and hereby indemaurrofinify
eprcu dcxxrofCit City menter Upon nst
awn mentioned property for inspection purpri
(Wc7 ague Ire an,indemnify and keep humless dm GIIY of Cupertino against
iN liabilities,judgmcnts,costs and expenses whichmryin any way accmc againsmidCity
U in consequence of thogunting of this Fcrmit. Date r�
APPLICANT UNDERSTA DS AND WILL COMPLY WITH ALL NON-POINT Issued by:
SOURCE REG AT1ON
A (10 Re-roofs
S,,mUU.of ApPlicanl/Cont.aor 11 Dam Type of Roof
HA RDO S MATERIALS DISCLOSURE yP
Will the applicant or future building occupant store or handle hamdous material
as re0ned by Oe CuKr ins Municipal Coda Chapter 9.12.and the Heald,and Safety
Code.Soctin.25532(.)? All roofs shall be inspected prior to any roofing material being installed.
Yo
Wil the applicant of furore buil Ing occupant use equipment or devices which If a roof is installed without first obtaining an inspection,I agree to remove
harsNnus air contaminants as recd by the Bay Ames Air Quality Management all new materials for inspection.
via?
❑Yes 0N
1 have head the ho.00Ns materials requlumetits under Chamc,6,95 of dm Califao-
niaH W&Safety Code,Secoons 25505.8533 and 25534.1 undersand Ow if the building
docs not currently haw a meant,Oar it is my responsibility or timely de occupant of the
mgoimmcnu which most be our poorpissuance ofa Ccf ifca¢of0c $ignature of Applicant Date
All roof coverings to be Class"B" or better
Owner or auto and.gen /1 Date