06030066 CITY OF CUPERTINO •sem" s '.� "+ = s°-
BUILDING DIVISION PERMIT C,oI.V112�i' CTURINEURMATION:
BUILDINOADDRESS: PERMIT NO.
06030066
O a: O UE CT PERMIT Issue DA'Z'E
SANITARYN LNO.
ARCHITECT/ GINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
i p LICENSED CONTRACTOR'S DECLARATION Job Descri L100
1 W hyy affirm that I am iicansed under provision of Chapter 9(Commencing P
a with Seclion70011)of Division 3 ofthe Business and Professions Code.and my lkensc is
E in full forte and ert -L L/j Z
isp uAmnso'clasa�l 9l UC.
0aw w REPLACE (E) LIGHTING-NEW PLUMBING FIXTURES
i ARCHITECTS DEC LA ATION CAN LIGHTS/OUTLETS/SWITCHES
I urs craund my plans 0.11 he used As public records
+u ARENA CONSTRUCTION PD FOR BL ON 20186 HOGUE
),rg,
Licensed PmfcssionJ
�j OWNER-BUILDER DECLARATION
f I bencsy.(fere that I em exempt Imre tie Conuanofs :Any C Law for lbe
a O following¢area Permit
t 7(13 1.5,Business and Professions Calc:Any oily m County
S which requires a permit m ennfwCt.Etter,imPmw,demolixh.Or mPolr any awctum
.„ Prim m its issuance,also mquiru the spphCool for such permit m file a signed statement
ito ylheisllmnsedformer tothe provisions of%.Contractor's Licen¢IAw(Chopter9 Sq.Ft. Floor Area Valuation
-a du
(Commencing with Section 7000)of Division 3 of the Busineand Profcasimu Coca)or
w that he Is exempt therefrom and the basis fm ibe alleged exemption.Any violation of
Section 7031.5 by any applicant fer a permit subjects Je applicant to a civil penalty of APN Number Occupanc
not mere than fns hundred dollars(SM.
D I'm Author ort a Dropmty,army employees whir wages u thetr Cole compemmvtion,
willdo the work end thesuucrum is notimended or offered forsale(Sec.7641,Business
and Professions Code:The Comovar'a Litttve Law does not apply m An owner of 316 2 4 0 4 0 . 0 0 Required Inspections
property who builds orimproves Narcan,sedwhodoessuch workhimselfor lmough his
Own emplayew.provided that such Improwmonts m,nm intended oroffmol fmsale.if.
however.the building m Improvement is mid within am your ofoompletion,Ne owner.
be.J. will ban the burden of proving that be did not build m improve for purpose or �a
eau.).
❑L as owner of the Sec.704.B sines And
contraProfte Ong With:)The
eonbaelms U.
conswm the project Apply
IOM,Bunion sed rty who ns Code:)The Comramafs U-
cense Lawmm dons not apply m ts owner of propens who sedbuilftp or improve themon.Cod,
who Conuecu fm such projects with a contranNttq licensed pursued N Bre Connxnoh
son.
0 1 Am 1 em exemq undo Sec. .B&PC for this rtamn
Owner Dau
WORKER'S COMPENSATION DECLARATION
1 hereby affirm under Pen IY of Perjury one of the following dmlarstions:
1 hsw and will maintain a CeNOcam of Consent to wlbfnsum for Woraces Compen.
sa0on,as Provided for by Section 3700 of the Labor Cade.for the performanca of Je
work for which this permit is issued.
D 1 hos and will maintain Worker's Compensation Inmranca.As required by Section
37W of Ne LAW Code,for the performance of the werk for which this permit is Issued.
My Worker's Compenraf o Insurance carrier and Polity number a¢:
carrier. c_Aq 's ti Cl Policy NA.: 17,7II9r1 `V S
CERTIFICATE— OF XEMPTION FROM WORKERS'
COMPENSATION INSURANCE
mtheecdmm need not becmnpleed lithe remit hsfhromhundmd dollm($IW)
or las)
1 ttnify the in the PuTiMMUce of the work for which NB Permit Is laced,)Nall not
employ any person In any mannerm As to become subject to fe Worker'Compewfon
Laws of CAnIMCIL Data
Applicant
NOTICE TO APPLICANT:If,after making this Certificate of Exemption,you should
become subject in the Worker's Compeosafnn provisions of the Ilse Cade.You muss
0 forthwith comply with such provisions or this permit shall be deemed ranked.
CONSTRUCTION LENDING AGENCY
I hereby affirm that them is a corawctinn lendingageecy fm the performance of
7 the work for which this permit Is issued(Sec.3097,Civ.C.)
1<ndefs Name
z Lender'sAddress
Q I cavity that I haw read this application and sure that Use Above information is
chnecL 1 agree to comply with all city and county ordinances and cum laws relatinginbuilding Construction,and bunchy Authod¢representatives of this city to enter upon the
L4 shove-crentiomd Prepcny for IMPAmIOA Purposes
gy (We)agree th saw,Indemnify and keep harmless the City of Cupertino against
w liabilities,judgments.ensu and expenrM which may In anY way aCCMe 99MMldd City
2 In consequence of the granting of this Permit.
^� APPLICANT UNDERSTANDS AND WILL COMPLY WITH AIL NON-POINT Issued by:9 Date �5—,17_so
SD REGULATIONS. q— t.� — b
Re-roofs
Signuunc ofppIINunwher
AZARDOUS MATERIALS DISCLOSURE Dam Type of Roof
I the applicant or future building mcupartatote orhandle hvs dons material
As defend by the Cupertino Municipal Code,Chapter 9.12,and the Health and Safety
cork.Section 25532(a)7 All roofs shall be inspected prior to any roofing material being installed.
❑Yea jkto
Will the applicant or future bulldinIl occupant use cyuipmanl or devices which
If a roof is installed without first obtaining an inspection,I agree to remove
hasaw rdnair contaminants as defined by the Bay Arta Air Quality Management all new materials for inspection.
x0ini
DYca �No
I haw and the huwdmmm=idsmquimmenuunder Chapw6.95 of Ne CAlifor.
ole Health&Safety Code,3ectiom 25505,25533 And 25534,1 understand!Phatirfe building
does not currently hew a unant.Wl it Is my ncapoMisililY m notify the ucsuPanl of Ne
MENJAMPAQ which must be mel Prior,w ismancaofa CaMncam of Occupancy. Signature Of Applicant Date
3-n -ob
ower ar ant need agent Dam All roof coverings to be Class"B" or better