04080054 CITY OF CUPER'1'INO
BUILDING DIVISION PERMIT CONTRACTOR INFORMATION ,
BUILDING ADDRESS: S .E.A. CONSTRUCTION PERMIT"04080054
2991C) TIAMMOND WAY
OWNER'S NAME: PERMIT ISSUE DATE
WE: SANITARY 918. C NTROL NO.
ARCHITECT/ENGINEER: BUILDING PERMIT INFO
BLOC ELECT PLUMB M[CH
0 0 M 0
u m Z LICENSED CONTRACTOR'S DECLARATION
y Om F 1 hereby affirm that 1 am licensed un Qterprovisions of Chapter 9(commencing Job Description
Qu
w with Scetion7Qx fDheirme3offle Busincs}/atd Professions Cade. emyliccnx is
in mu refs anq eft. /•• ADD 336 SQ. FT. (OFFICE/STORAGE)
Lic
c x Cla Lic.M
K H❑ Dam) c,mractor LD V
'IJ ARCI TECTS DEC 1
eI understand my plans shell be used az public mcnNs
;0,t
v, Licensed Pm(cssionel J
a OWNER-BUILDER DECLARATION
<S 1 hereby affirm Nat 1 em exempt from the Canuactor's License Law for the
'0 following mason.(Section]031.5.Business and Professions Code:Any city or county
K m which requires a permit to cnnstmn,start.improve,demolixh,or repair any structure
m—w pride Of its issuance,also requires the applicant(of such permit to file a signed statement
zzEa that he is licensedpursuantmlifeprevisionsoftheContranor'sBeen.Low(charter9 Sq.Ft. Floor Area Valuation
"C (commencing with Section 71)(0)or Division 3 of Ne Business and Profusions Code)of
i�_ that he u exampt dumfound and that bxeis for the alleged esemption.Any violation of
section]031.5 by any applicant for a pmmlt subjects the applicant to a civil penalty of 3 �gr00 Occupancy Type
not mom bean five hundred dollars(5500). v ,
1,as ownu of the property,or my employees with wages as their sole compensation,
will do Ne work and the structure is not intended or offered for saic(Sce.IOb,Business Required Inspections
and Professions Code:no Conuactor's License Law sou not apply to an owner of q p
property who builds or improves thereon,and who does such work himself or through his
Own employees,provided thntsuch improvisational;are notinleneed hindered forsde.If,
however.she building or improvement is sold within one year of completion.the owner-
builder will have the burden of proving that he did not Wild or improve for purpose of
sale.).
❑1,as owner of the property,am exclusively comforting with licensed conuaclors to
foremost the project(Sec.7044,Business and Professions Code:)The Conuacwr's Li
conte Law does not apply to an owner of Furst who Wilds or improves rimmed,and
who contracts for such projects with a edmracuu(s)licensed pursuant to the Conuaetor's
License Law.
C] I am exempt under Sec. .B&P C for this ream
Owner Data
WORKER'S COMPENSATION DECLARATION
1 hereby affirm under penalty of perjury one of the following dalvatidns: -
have and will mainmin a Cntificsle of enamor m self-insure for Wohers Cumprn-
Lionsaiion,res provided for by Scion 3]00 of the labor Code,for fire performance of be
.
which Nis permit is issued. -
1 Mac and will maintain Worker's Compere lion Insurance,as required by Section
]]00 rf Ne Labor Code.for the refformana of Ne wmk far which this permit is issued.
My WORch Compensation lnaurar�klc and Policy number am:
C mer: ✓`carom andPolicolicy 3�q
CERTIFICATE OF EXEMPTION FROM WOn EMS'
COMPENSATION INSURANCE
(Thu section need not he completed if the permit is for one hundred dNlars(SIM)
nr IcSa.)
1 cenify that in the performance of the wart for which this permit is issued,1 shall not
employ any permany manner so as to become subject to the Workers'Crmpensuuon
Laws of California!Date
Applicant
NOTICE TO APPLICANT:IL tiler making this Certificate of Eacmptitso you should
become subject to the Worker's Compensation provisions or the labor Cute,you must
.J O foMwith comply with such provisions or this Permit shall W deemed revoked.
Z " CONSTRUCTION LENDING AGENCY
Ihereby affirm that there is a construction lending agency for NC Performance of
the..,it for which Nis permit is iumd(Sec.309],Civ.C.)
Lenders Name
=z Lender's Address
U C) I cnuft,that 1 have mad this application and sum that the above information is
torten.l agree to comply with all city and county ordinancces and sum laws relating bo
0V Wve-mconswctidn,and Wmbydermus crtprexnUtiws orhis city menter upontW /h
G shout-
(We)
agree
property for emnity an keep ha /
(Wt.)agree a ssw,indemnify and tech may
m dm Cue of Cupertino against
UN incoiseq enceO the coming expiS Permit. may in any way accrue against said City
V z info CAN"cc of UNDERSTANDS
Nis Permit.
.. APP (CANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT Issued by: Date
s0 GULATIONS. _
���'�y Re-roofs
gni ofApplicaHAZARDOUS MATERIALS DISCLOSURE Date Type of Roof
Will the applicant or future building occupant store or handle havardous mamnal
as defined by the Cupertino Municipal Code.Chapter 9.12,and the Health and Safety
Cole,QYca 25532(.)? Na All roofs shall be inspected prior to any roofing material being installed.
Will the applicant or mime building occupant ase equipment or devices which If a roof is installed without first obtaining an inspection,I agree to remove
t haltious air contaminants u doffed by tW Bay Area Air Quality Management all new materials for inspection.
ms? yyyy
❑Yes 67 Nu
I have real the haardous mamrials aquiremcw under Chapmr Q95 of the Glifdr
nit Health&Saet,Code,Sceuaa25505.Z5533 and25534.1undernard thaziftM Wilding
gas net Currently haw•tenant that ibis my rnpaaiM1ilitY to ndtily the acupanl of d¢
requirements which most the mel prior W issuance of a CntlBcat,o�cupancy. Signature of Applicant Date
own ranmaria.eeasem d, All roof coverings to be Class "B"or better