00070039 CITY OF CUPERTINO
BUILDING DIVISION PERMIT . CONTRACTOR INFORMATION:
Ru1LDIbc NICLCREST 'RD BARNES PERMIT No�00700J9
,;OWNER'S NAME: APPLICA99 I
BARNES V9/2000
HONE: w O� - SANITARY NO. CONTROL NO.
❑z Z ARCHITIECTIENGIN EER: BUILDING PERMIT INFO r '
�u O FO BLDG ELECT' PLUMB MECH
< LICENSED CONTRACTOR'S DECLARATION M1
z 5 y z Job Description
0•-❑ Ihereby.ffrm that a.licensed JrP tovi.' n. sr Chaped,9mommmrcing s ,
Iinran t 9000) fU 3 fah B dP f:' mdnry rcens
a im f a ur R RECEPTACLES
as
°Kt0ica Done - - Contractor
- -
ada.so
ARCHITI Cf S DECI ARAE ION
n ' 1 understand myplans shall M1 s I"pll ..to,
so�r
6=0 Licensed Pf.. I
OWNER-BUILDER OLCLARAI'ION
='
TI hereby 0 that 1 'e p, nth C tar ta r L L far the
toll
Z g (S t 9(1315 B d l f C I Y m aunty kD
iS as whmh ey u s e nn u o Boat alt r improve,J b hrepairy.nctoon,
3- ph t t: y ' to �[.I f C rlo mu tl E d.tamen - .
marl :licensed P n m g n : nn t t L L on,Cor9 Sq. Ft. Floor Area Valu
(co.,,bar
he is o eralSeU on 90W)of Division 3 none Bam d i Profession,Code) 1
ov that he is exempt forany a ora and the basis for the alleged ppluda n to Any l penalty .+
of Sectioneth n v anyapplicantfor apeonit suhjcn;the hPplirmt toacivil penalty
or not more ntnn five hundred dollars fssw). - APN Number Occupancy Type ,
❑I,as owneroftlert,ora race.with woes as their sole compensation, 32616055. 00
grope ) yemn r s
will do the work,and the xtmeture is not intended or osreral for sale(Sec.90i4, gel q�
Raines=and Prnfession.s Cale The Cm hademr•s License Law slows not apply m an ?04. — ROUGH ELECipN IId& '
w r of progeny Who builds or improves thereon,and who due.such work himself �,
ar 11 ugh nix awn employees,provided that such improvements are not intended or
t 'oaerca far side If.howcve,the ncilding or impmvement is x„w within one sad,of ” 501. - FINAL ELECTRICAL ENERGY
temple,on,the owner-bander will lntve the folderol pro ing aha,he aid aid haild or .
im,ameforpurpooerf.,ale) 505 ,— FINRL ELECTRICAL
❑I f thep pcny lycontracting with licensed I w a i
w ,ucuh
Protect ts 9044 Buslt:. and Pnf Cd 1Th Contractor's
o - -
License
i en L J :n ,appl , a n t property h M1 Id: p n
and who contracts f h.projeets with contractors)licensed pursuant to the
Conmetors License Lnw'. -
❑I am exempt,oder Sec. B&P C for this reason
Owner hate
WORKERS COMPENSATION DECLARATION
1 hereby affirm order Penalty or perjury one of the following declaration, '
.l 1 have and will maintain a Carapace,of Consent in self-insure for Worker's
Compensation, as provided for by Section 391111 of the Labor Code, for the -
perforntanceof,he work for which this peorit is issued.
I have and will maintain Workers Compensation Insuranm,as required by Section _
011 of the Lalwr Code,for the portion urnce of the work for which this permit is _
Issued.My Worker's Compensation.Insurance carrier and Policy number ire ,
Carrier: Policy Na: o:
CHID ipICA'rioN OP EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE.
(I his section need on,be eomNeted if the permit is rnr one hundred dollar,
o 100)on less.)
I ,
1 certify that in the perlommnce of the work for which Ihis permit is issued.1 .
shall not employ nny person in any manner so as to bcamoo subject to the Worker, - -
Compensation Law-v of California.Data,
Applicant
NO]'ICE'PO APPLICANT:If, Recrossing this Certificate of Exemption.you should _
became subjecu m the Worker,Compensmton ginsist anv of the Labor Code,you educt
Q O lonhwlth comply with,inch Provisions or this pr mi,shall be licensed revoked. -
F4 CONSTRUCTION LENDING AGENCY
rj .thereby affiriatwhich that Dmai,is construction lending agency for the performance ,
W Lender's
work N tar which this permit Is ismscd(Sea 1097,Clv.C.) ,
Lender's Nvme
Q
Lender's Address
V 0 [certify Ihaol have rend this application and state that the above information is _
W Fal correct,I agree to comply with all city and county ordinances and sate laws reining I
V to building consmction.and herehyunalmi,c representative,oflb,cil,1.enter upon -
sy W the nM1ovenremioned punpony for inspection puvpases. '
iiis
Fy y es,judgments,
agree ts,cost and expenses
mus which
in the City of e......against
� liabilities,jndgmcnts,rows and expenve,<which may in any way uwmc against Buie ,
V Z City in eomsequenec of the sterling of this permit. rip -
r SOURCANTCN ERSTANDSANDWILLCOMPLYWITHALLNON-POINT Issued by: I �K Datelb"""w
Signauve of ApPlicanVCnmracnm Date Re-roofs'
HAZARDOUS MATERIALS DISCLOSURE '
Will the applicant or main,building oecapant store cr,,naaue faaardntts material Type of Roof .
;is defined by the Cupertino Municipal Code,Chapter 9.12,and the Health and Safety
Code,Section 255321,)4 ,
ores 73 No All roofs shall be inspected prior to any roofing material being installed.
Will the applicant orfuture building occupant use egnipmemer devices which If a_ roof is installed without first obtaining an inspection, I agree to remover,
nit hnnaNam air cameminans a,duhned ny,he BeY Arcu Air QuulitY Mnnagemcm
astdetp - all new materials for inspection. Applicant understands and will comply with I .
ores ❑No' all non-point source regulations.
1 have re,d the haaardom material,repeamau nuc ander Cramer 6 9 of the
?California Health&Safety Code,Sections 25505,25533and 25531.1 understand that
iflhe building does not currently have a forum.that It is my responsibi lily to notify(lie, r x.
enpnm of tit equir n cots which must be t prion,issuance of a Cenificmc o
ne e t
Occupmt�. � � '
�6 Signature of Applicant Date
Oso,rornumad,ed'agen, - n,e. .All roof coverings to be Class `B" or better
OFFICE