04050080 CITY OF CUPERTINO •";: ax..aea g '°'"� ••"' f"��""
BUILDING DIVISION PERMIT pCONTRACTQR INFORMATION ,, -
BUILDINGADDRESS: AC CONSTRUCTION PERMIT Nrb4.0 S 0080
41 r� NRNRY CREEK P1,
OWNER'S NAME: PERMIT ISSUE DATE
MAJBBD NOVB
E: SANITARY NO. CONTROL NO.
(408) 374-1497
ARCHITEC(ENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
0 0 0 0
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LICENSED CONTRACTOR'SDECLARATION Job Description
U 1 hereby,affirm that I am lien""d sealer pmvbdom dr Chapter 9(commencing
W with Section 7M)ofDIA,kn 3af the Butinssend Prafevdims Code.uM my licenuu
a�a in mu force and affect. REVISION--IN HOUSE USE ONLY
j q b License ClawLk.R
=:c Dam contractor NO NEW PERMIT ISSUED/ORIG. 404030035
try ARCHTIECI-S DECLARATION
I undersand my plans shall W used as public meads
odU
GI' Licensed Prutcasional
S OWNER-BUILDER DECLARATION
yq I hereby mrrrm Nat 1 am exempt(rum the COmractors Licence Law for the
i O D following mason.(Section 7(13 1.5,Business and Pro essiann Calc:Any City or county
v�$ which requirca a Permit to cnruwct,altar,improve,demolish,at repair any structure
r=6 prior to ire Washon.also mpdoes the applicant for such permit to rile a signed suumat
FFm Nat he,is licensed pursuant to the pmvisiouoftheCommnar's sconeLaw(Chaptv9 Sq.Ft.Floor Area Valuation $p
yF$ (commencing with Section 7000)of Division 3 of the Busineas and Professions Code)or
.-
that he is ucmpt themfrom and an,basis for the alleged eumplan.Any violation of
Section 7031.5 by any applicant far a permit subjects the applicanno a civil penalty of APN Number Occupancy Type
not mom Son rive hundred dollar,a51](1). 34248021 . 00
❑1.ss owner ofdu psopeny,o my employees with wages as their sole compensation,
will da the work and theurucmm isnot daunted ooirarud fortud, See.71NC,Business Required Inspections
and Ply wh ov Cak:The Convector.Licenm law docs not appy m an owner of q \
plainly who s.provi improvescanon,endwftswe not historical work himselfar through hu
own employees,p ing a, himummhat Such impm old Wit in not aroferaNclioraffeed fous.due O n.Ir- \
Insider Nebuildingorand Of .ArissoldwithinaneyearormproefarNeowner-
builder will hese the WNen of pmvin6 that W did not build or improve far puryose of <g�
syya 1. V_
co Les owner of the property,am sed ss and contracting with:)The
mmences U. \
construct closer
project(Secapply
to an wner of
and rty who ne,Wilds
ds or
Theme,the cars ad \
who c law does not apply m an owner of pmperey who Wilds as improves theman,and
who concocts for such projects w' aconvacmKs7licenxtl pursuant mthe Convumrs� �
License law.
oiunuemptunder See .B&PCrrthie reason
Da
KHR'S COMPENSATION D4WRTI
//hem afrvm under peruBy of perjury ane oflW r kwinj declaradov:
fiam and will maintain a Ccniricau afC.O.Ot m self-insure for WokehCompen-
mn,as provided for by Section 37W or the Vbor Code.for dm Performance of dm
work far which this Permit is issued.
❑I have add will maintain workers Compamadon Insurance,as required by Section
37W of the Labor Coda,for Ne performance of the work for which this permit is issued.
My Worimes Compensation Insurance carrier and Policy number ase:
Cartier. Palicy No.:
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(Thiasnctian reed not W camplced irshe permit is foro mfout rod dollars(SIM)
or less.)
I certify thus in the prolone ecu of the.,it far which this permit H mused,I.hall nus
employ any person in any manner so u m Walla Subject in the Wuhan Compensation
Laws of California.Dam
Applicant
NOTICE TO APPLICANT:If.after making this Ceribcase of Exemption,you Shand
became subject in Ne Water's Compensation provisions of the Labor Cade,you muse
0 Z forthwith comply with such pmvWnm or this permit shall W dcemed revoked.
zO CONSTRUCTION LENDING AGENCY
(-.� 1Wmby affirm Nat Nem iso mtmuuctinn kndingapeney far the perfufmmceuf
C 7 the wish fur which this permit is issmd(Sec.3091,Ci,C.)
Q Lenders Name
=z Lenderi Address
U 0 1 certify Nat 1 have reed this application and lute Wt de Show ad find is
IL F conch.1 agree m comply with all city and county Ordinances and sum laws missing to
OU building construction,and Wrcby ambome mpresenmives of this City m came upon the
}fU above-mentioned property for inspection purpoess
mear do City of Cul-i
Fry Iiabilitin.Wjudgments.mu and expenses whree in Saw,uniformly and hiicch may in any way acerue.g nsltsaid gains'
U2, meanuqucnccofthernlidganhisparmit. Dale
^ APPLICANT UNDERSTANDS AND WILL COMPLY WITH AL NON-POINT Issued by:
SOURCE �
/ � / Re-roofs
um br pplmantlConuumr ata Type Of Roof
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future building ampere store or handle hvardaus material
ss defined by Ne Cupertino Municipal Cask.Chapter 9.11,and the Health and Safety
Cole.Section 15532(.)?} All roofs shall be inspected prior to any roofing material being installed.
❑Yu ®No
Will the applicant or future building occupant use equipment or devices which If a roof is installed without first obtaining an inspection,I agree to remove
havardnus air contaminants ss defined by the Bay Arca Air Quality Management all new materials for inspection.
vin?
❑Yes �No
I have mad Ne b rardous materials requirements under Chaper G95 of the Califor-
niaHcahh&SafclYCodc.Secdotn 25505,25533 stru a.1 undcrserul thatifthe Wilding
does ms currently ..am nane thv it is my rcaponsihilisy a nudity the capent of the
reyuimm coca of aCaNnca inwcpmcy. Signa
coca Date
cored agent BulkAll roof coverings to be Class "B" or better