04020152 CITY OF CUPERTINO '" +
BUILDING DIVISION PERMIT � eONTRATQR+INFOBMATIQN�;;
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BUILDING ADDRESS: PERMIT N0.04020152 4020152
OWNER'S NAME: PERMITL UE DATE
L
NE: SANITARY o. CONTROL NO.
ARCHITECT/ENGINEER: BUILDING PERMIT INFO
SLOG ELECT PLUMB MECH
upQ
LICENSED CONIRACTOWSDECLARATION Job Description
C 1 hereby affirm Nat 1 am licensed under provisions of Chapter 9(commencing
U wit Section7")of Division 3aflhe Business and Professions Criminal my liccnu is
a in full foreeond effect.
5 = License Class Lae.« CARPORT ENCLOSURE & DECK UPGRADE
;:, Dam GSDECr (224 SQ• FT. )
€ ARCHITECTS DECLARATION
C-I 1 understood my plans shall he used as public records
u.G Licensed Professional y
3 OWNER-BUILDER DECLARATION /
aI 1 hereby affirm Ont 1 am exempt from the Conrmots License Law far the
j:00 following reason.(Section 7W 1.5,Business and Professions Code:Any city in county
which requires a permit to construct.eller,impmvc,demolish,or repair any structure
prior in its issuance,also requires the applicant for such permitto Glc a signed s wcomid
that he is licensed pursuant m the provisions Of me Convector's License Law(Chapter 9 Sq.Ft. Floor Area Valuate fib
FFG (commencing wit Section 7")of Division 3 of to Business and Prefessions Cute)or 4J1v/LvJ 1��. V�
y $ tad he is exempt dheefrom and the,basis for to alleged exemption.Any violation of
Section?031.5 by any applicant for a peril subjects to applicant to a civil penalty of AIN Number Occupancy Type
not mom tan five hunted dollars($500).
01,as owner of the property.or my employees with wages as their sole compensation, 32616089 . 00
will do to work.and to slmmum Is nod intended or offered for sale(Sec.7060,Business
and Professions Codc:The Contractors License law does not pply to an owner of Required Inspections
propeny who bui Ids or improves thereon,and who doca s uch work hi rose If or trough his
own employees,provided mal such improvements we not intended or offered Interim.IL
however,to building or improvement is sold within one year of completion,to owner,
builder will have the burden of proving tad he did not build or improve for purpose of
sale.).
as owner of the property,am exclusively channeling wit licensed convectors to
ons et to pmject(Sec.2000,Business and Professions Code:)The Contractors U.
cense law does not apply to an owner of property who builds or improves tenon.and
who contracts for such projects wit a contractor(a)licensed pursuanuo to Convacdor's
License Law.
❑lam p der See. .B&PC It,this mason
if
er �Aate t 0
COMPENSATION DEC DATION1 hereby allir under Penalty Of perjury ON Of me following deelaratihns:
have and will maintain aCeruficae m
of Consent to self-insure for Workers Chmpe
cation,m provided for by Section 370 of IN labor Codc,for the pcimrance of to
work for which this peril is issued.
❑I have and will maintain Worker's Compensation Insurance,im required by Section
TIDO of me labor Codc,for the performance of me work for which mis permit is issued.
My Worker's Compensation Insurance canter and Policy number ate:
Cartier, Policy No.:
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(This section need not bacompleted if the permit is for one hundred Oulars($100)
Or less.)
1 certify mal in me perforanee of the work for which his permit is issued.l shall not
employ any permn in any manncrso as to become subject to the Workers'Compensation
Laws of Califomia.Data
Applicant
NOTICE TO APPLICANT:If,after making mis CeniGcam of Exemption,you should
become subject to be Worker's Compensation previsions of to Tabor Codc,you most
.J Z forthwith comply with such provisions or this permit shall IN deemed revokhd. -
ZO CONSTRUCTION LENDING AGENCY
[-. I hereby affirm that dere is a construction lending agency for to Performance of
C(i > he work for which dis perit is issucd(Sol.3197,Civ.C.)
W Q Lender's Name
a. fender's Addrem
U C) 1 certify mad 1 have read mis application and sum that me above information is
ly f" conecL I agree to comply wit all city and county ordinances and stare laws relating to
V building construction,and hereby aumone numanindives of this city m enter upon me
U shove-mentioned popery for impeNon purposes.
(We)ague to save,mh moi fy and keep harmless On City of Cupertino ageinsl
i h liabilities.judgments,costs and expenses which may in any way aecom against said City -
U Z in consequence of On gaming of this permit /
^� APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT Issued by: Date
SOU TONS.
Re-roofs
Signature fAppicanUChntrattor ale
HAZARDOUS MATERIALS DISCLOSOICE Type of Roof '
Will the applicant or future building Occupant stem or handle hmsrdous material
as defined by the Cupertino Municipal Code.Chapter 9.12.and de Health and Safety
Code.Section 25532(a)? All roofs shall be inspected prior to an roofing material being Installed.
❑Yesn P P Y g g
wm me applicant or mem bunting ocehpant use equipment or envies which If a roof is installed without first obtaining an inspection,I agree to remove
I baO.ardous air contaminants as defined by the Bay Arca Air Quality Management all new materials for inspection.
District?
C]Y., )B�lo
I have mal the haauNnus mamnals requirements under Chapacr 6.95 of me Califor-
his Hc,dut&SamlyCodc,S..a
equireenvunderChapur6.95ofineCalifor-
hisHcaut&SamlyCode,Sacbom 25505.25533 and 35530.1 undersand mal if the building
does not current y have a tenant that it is my responsibility to nodly the cecupant of me
requiem atxmet prior I.ismanenracemBeatenr cpanc Signature of Applicant Date
Ornramm�naedasenl a oath All roof coverings to be Class"B"or better