04030035 E":LEBDING
TY OF CUPERTINO p <'�' +
BUILDING DIVISION PERMIT CON TRACTOR IN MA I(1N.
ADDRESS: AC CONSTRUCTION PeRMIT'004030035
ER'S NAME: PERMIT ISSUE DATE
MAJ
EE: SANITARY O. CONTROL NO.
ARCHITECDBHGINBER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
t� 0
LICENSED CONTRACTOR'S DECLARATION "
lyFF lob Description
I homey affirm that I am licensed under provisices of Chapter 9(commencing
t� with Section 7=)of DWidmn3-fdm Business and Prefessiom Code.and my licenseis
cforce and
Class Lk.N CONVERT DECK T 4AqLFW
Dam ContractorARARCHITECTSDEDECLARATION
o 1 understand my plana shall he used as public record
i� Licensed Pmressionall cerj r� U V
OWNER-BUILDER DECLARATION LLJ C'U
<S I hereby affirm that 1 am esempt from the Guarantees License Law for the
O 0 following memo.(Section 703 1.5,Business and Pro(esdom Code:Any city or county p
s$ which re mea a permit to comwct,alar.improve.donnish,or repair my someone t:
111"4113 ISmUce,aku mquims ll or
the applicasuch permit to file 1111011 atatemenl —
< IhuhcisllcemedpurmantodeprovislomofduConuacor'sLimmcLaw(eMpur9 Sq.Ft.FloorA b� Valuat on
D (cmernai,with Smile.7000)ef Division 3.1'the Busmen and Profersi-m Code)Or
$ that he 3.tempt durefmm and the basis for the alleged exception.Any violation of
Section 7071.5 by any applicant for a permit subjects the mplinnl In a dvll penalty of 3 4'K��I$'0@dTerO O Occupancy Type
Out mall man ave hundred dollars,(m), -
0 1,as owner of the property,or my employe¢with wages as their sets tmmpemadon.
will do the work,and thnncnue is rot intended or-Beard fn,sale(Sec.7044,Business Required Inspections
and Professionalcode:Tim Contractors License law does set apply m e an Omer ser q P
pmpenyohm beiId-rimprmea tb mm,andwhodoeeuch workhimselfor Ihmugh his
mw employees,provided that uch impmemenu ase notintended cropland for We.If.
however,the building or improvement is sold within one year or completion.the Owner.
builder will loom W burden of proving that be did not build Or improve far purpose of
u mwmr of the SecRny,ran e¢Iwiv A cmnusctcng with seemed contretors U.wet de esproject(Sec.70,14.Business rod ny who
ds or I The es theme, red '
come law dose not apply man owner of pmpany ohm build or improves Merron,and
whene,tracts LA.
0, an VWfor such projects with e
WiacanulicensedIlceed pursuant uootheCmtretor'&
Licesm ase p d Sec .B&PC fw rola
� P
1 hereby a no under penalty of perjury we of the follow n{declssotiom:
I low and will maintain a Certificate or Cannot o elbimure fm W~s C-mpm-
asdcn,u provided for by Section 3M of the Labor Cod.fm the performance of the
work for which anis permit is issued.
0 1 how and will maintain Work es Compamdm Imuran,as acquired by Section
370D of the Labor Cede.rot the performance of the work for which this permit is Issued.
My Worker's Compensation Insennce carrier and Policy number ell:
Cmier. Policy No.:
CERTIFICATE OF EXEMPTION FROM WORKERS
COMPENSATION INSURANCE
(Thissectio need ml he comp lead if the paw It is forme hundred dollars($10111)
or less.)
1 cavity that in the performance of IM work for which this pemlit Is,issued.)shell not
employ any person in my mmmr an u o become subject to the Wmrkes'Compew0en
Laws of Callfcws Data
Applicant
NOTICE TO APPLICANT:If,after making this Dominate of Exemption.you should
become subject In the Worker's Compensation provisions of the Labor Code,YOU marl
OZ forthwith comply with well provisions or this permit shalt be decreed rcvNmd.
z CONSTRUCTION LENDING AGENCY
[—i I hereby aplw than them its construction lending agency for the performance of
ai> the work fm which this permit is issued(Sce.3097,Ci,C.)
W Q Lcmices Nunc
z Lender's Address
Cp Q I certify a the I haw mad this city
and
and sum that the show im miNm In
0 t cowc4 l o me c comply with all airy W cams ordinances and emu Inn rmistingupt e
0 qi.'J mov building enntwetpro and fombyaummimmeards. iwa-(Nin city to enter upon me
W rMva (We)a re progeny for Imnifyon puryoses
o
(We)agmen 41 saw,indemnify sed harpmay
inburette,the City of Cupertino agsiml
U r/� in
nconsequence
oiduunce ofueem3md expenses which mrynn mywYacrnu gainesaid City
V F'l7 inPPLICA nccof DERSTbngof DSnhlspc LL COMPLY WITH ALL NON-POINT Issued by: Date
OIR I
AD Re-roofs
t_HAZARDOUS MATERIALS DISCLOSURE Date Type of Roof
Will the applicant or(umre building Occupant store or handle hanadous material
m defined by me Cu Ino Municipal Code.Chapter 9.13,and the Hmlth and Safety
Alftda.S 0 edea zss32(r).Yea e All roofs shall be inspected prior to any roofing material being installed.
:Di.u11,ct7
ill the applicant or fu um building¢�eopen%use equipment or devices which If a roof is installed without first obtaining an inspection,I agree to remove
nims air comamimmus u&need by the Bay Amo Air Quality Management all new materials for inspection.
0Y1shae mW the hrsndtolmateriels requirements underChapon6,95 orthe Califonh&SaWyCoW.Sectiom25505,25533 and2l534.1 understand matlfde Wilding
unendy Mw a tenanl.deln k at ,asp-ability o unify de aceupanlat e
n3 -racenDf. a sup r. Signature of Applicant Date
a Dee All roof coverings to be Class"B"or better