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CITY OF CUPERTINOr
ICONTRACTORINFORMAPiRN e
BUILDING DIVISION PERMIT
BUILDING ADDRESS:
PE "NO.
04020158
OWNER'S NAME:
PERMIT ISSUE DATE
E:
SANITARY N 0 OL NO.
ARCHITECVENGINEER: -
BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
LICENSED CONTRACTOR'S DECLARATION
Joby-fS77RRa..,,,n
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I lamb, aMfm that I am licensed uMer pmu visioof Chapter 9 (commencing
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with Section 7").f Division 3 O du Business and profusion., Codc. and my license Is
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in full force and effect.
DEMO
License CleatUe.«
Date Lic.#Contractor
MAR 1 5 2004
ARCHITECT'S DECLARATION
I understand my plans shall W used as public reeordx
Bull
Licensed Pmfessi ... I
OWNER -BUILDER DECLARATION
1 hereby affirm tint I am exempt form due Cannaclah License Law for the
(Section fallowing moon. (Son 7W1.5. Business and Prefeeaiuu Code: My city nr county
which rtquims a Permit to cdtxaaet, alter. improve. demolish. Or .pair any someone
Pod mire bandana,., also rtjui. Ne applicam for such permit m Ole a aimed mo mem
Sq. Ft. Floor Area
Valuation
that he is licensed punoenllo the Provisions nftuCimfumn's Lincom isw(Chaptcr 9
(commmuing with Section 7T00) of Division 3 of the Business and Professions Code) or
Nan he u exempt therefrom and the buts for the alleged exemption. Any violation of
3MlY001171$eF00
Occupancy Type
Section 7031.5 by any applicant for a permit subjects the applicant to a civil Penalty of
not more than Ow hundred dollars (8500}
1, u owner of the property or my employees with wages as dxrsole campeovdon,
Required Inspections
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will do the work. and thea olue. is not intended oraiTuW faratue(Sec. 70th, Business
and Profeuiou Coda, The Conuannr's License Law does not apply to an owner of
9
property who WI1W or improves themon, and whodeessuchwoh himulfornhrough his
own employees. provided that such improvements an, not intended mastered fanatic. It.
however. Ne building or improvement 1s sold within ore year of completion, the owner -
builder will low the burden of proving slut he did out Wild or improv for puryose of
atic*.
X 1. se owner of the pmpeny. am exclusively convecting with licensed contraawn in
construct the project (Sec. 7044. Business and pretentious Cade* The Cantruwri Li-
cense raw does net apply to an owtw of property who Wilds or improves thereon, and
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who contracts for such projects with a convactor(s) licensed pursued to the Contactors
Lim. Law.
01 am ex rept under Sec. B& CC/fy. Nit won
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Owner Data " s '
- / WORKER'S COMPEN LION DELI
KATION
1 hereby affirm under Futility of perjury aneoane IOxawing declentiorts:
1 ban and will maintain aCeNOmu of Conud in self -insure for Wormer Compen.
.it... u provided for by Section 37W of the lsbaf Code, far the Nlformanm Of Inc
work for which this permit is issued
0 1 haw and will maintain WOnke's Compensation Insurance, as required by Section
37W of Ne Labor Code, for the Penformaruc of the work for which this Imit Is issued.
My Warkces Compensation Insurance carrier and Policy number am:
Cartier, Polity No,
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(7his ucdrn recd not W eamplewd If the Permit isformc humbeddollan ($100)
or less.)
I ceNfy that in dr. performance of the work Tor which this Permit is issued. I shall nut
employ any person many mare, u at to become subject to Ne Work a Coropeustion
Laws of California. Date
Applicant
NOTICE TO APPLICANT: IL after making this Certificate of Exemption, you should
become subject in the Workers Compdsation provisions of the ISWr Code, you most
fordwith comply with such pound.. m this Permitshail he dcemee revoked.
CONSTRUCcIONLENDING AGENCY
I hereby afford Net Vert is construction lending agency f or the Performance a(
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the work ten wnich this permit is iuvee (sec.Sm. 3W7, civ. C.)
Isndcr's Name
Addo
1<ntler's Mems
1 mind, Nat 1 have mad this application and sou Nan Na, thaw informum. u
' carmen. I agree to comply with all city and county Ordinances and suss laws misting In
Wilding construction, and hereby adhodre representatives of this city to enter upon Ne
I ahow-mentioned property for inspection purpaus.
(We) ague to ave, indemnify sed lamp hnmlecs the City of Cupertino agaius
liabilities. judgments, cast sed expeuu which may in anyway umuc aguut said City
r in coucgcence of the granting of this Pamirs.
APPLI NT UNDERSTANDS AND WILL OM W171/ ALL NON -POINT
Issued by: Date
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SOU U:::
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Re -roofs
Type of Roof
SI' sure OfMplicanVConaranm Dau
x HAZARDOUS MATERI DISCLOSURE
Will the applied or future building occupant sham or handle huardous material
as dcrined by the Cupertino Municipal Code, Chapter 9.12. and the Hcalth and Safety
Section 25532(a)?
0y.PNa
All roofs shall be inspected prior to any roofing material being installed.
iIfCode
a roof is installed without first obtaining an inspection, I agree to remove
Will the applicant or future building occupant use equipment or devices which
.n ham rdous air contaminants as defined by Na, Bay Area Air Quality Management
all new materials for inspection.
District?
DYu No
1 ban mad the hnudma materials requiremenu under Clau un 6.95 of Nc Califon
nu Health&SafetyCode. Sections 75505.25533 and 23534.1 understand Nu irdu Wilding
dare non c n ly naw a tempt Nat h is my respouibiloy notify Na, occupant ofd¢
rtyuino w' mux bemet mwismanceof.0 'm am ofA3rcupanry.
Signature of Applicant Date
co�C//ode
All roof coverings to be Class "B" or better
OwA6 or amt .e0 ascot