04010129 CITY OF CUPEWHNO + &• x z �<,;b �, s, l
BUILDING DIVISION PERMIT CONTRACTORANFORMATION
¢AHI
BUILDING ADDRESS: AN KY CONSTRUCTION CO PERMIT N004010129
OWNER'S NAME: PERMIT ISSUE DATE
AFFINITY EN
NE: SANITARY NO. CONTROL NO,
(408) 234-2673
ARCHITECT/ENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
uoo LICENSED CONTRACTOR'S DECLARATION lob DOSCrIPI100
YwF 1 hereby offcm Nat I am licensed under provisions of Chapter 9lcommencing
SZty with Seetion7")of Division Sof NC Business and Professions Code.and my license is
<n, mmuto=and effect. REVISION--HANDICAP PARKING
License ClassLica
;mac Dam COnwctor NO NEW PERMIT ISSUED/ORIG. #03090020
ARCHITECTS DECLARATION
1 understood my plans shall W uaed as public records
Jca
Ward Pmrcssional
OWNER-BUILDER DECLARATION
sq I hereby affirm that 1 am exempt from Nc Contractors License Law for the
00 following mason.(Section 7031.5.Business and Pmfexaions Code:Any city m county
$9' which requires a permit to construct,alcor,improve.demolish.or repair any structure
—Zaprior to its issuarmc.also requires the applicant for such pemtit to file a Signed Statement
hot he is time med pturstothl to the previsions of the Conlractor's License Law(Chapter 9 Sq.Ft. Floor Area Valuation $0
yts-O (commencing with Section 7000)of Division 3 of the Business and Professions Gulc)of
i $ Nat W is exempt therefrom and be basis for the alleged exemption.Any violation of
Section 7031.5 by any appliernt for a permit subjects be applicator to a Civil penalty of APN Number Occupancy Type
not mom Nan Bve hundred dollars($500).
01,as owner oftW property,or myemployces with wages asbeir sole compensation, 32609061 . 00
will do be work.and be structure is not intended croRered for salc(Sec.1064,Business
and Professions Code:The Contractor.License Law does not apply to an Owner of Required Inspections
property who builds or improve Hereon,and who does such work himself or through his
own employees,provided Nm such improvements am not intended or offered for sale.If,
however,be building or improvement issold within one year of completion.be owner-
builder will hoe Ne burden of proving Our he did not Wild or improve for purpose of
sale.).
0 1,as owner of be property,am exclusively contracting with licensed contractors to
construct the project(Sea 1040.Business and Professions Code:)The Contractor's Li.
nue law does not apply m an owner of pmpcny who Wilds or impmws thereon,and. , C
who counsels for such projects with a contractor(s)licensed pursuant tO tW Contractors V g^
Litems Law.
C]e se \ C�
minacmpt under S .B h P Cfo''r N--is�recon
ker Dam eq-i -
WORKERS C EN ATION DECLARATION
I Wteby affirmunder pen a !jury oto ft dllowing duWniov:
0 I have and will maintain a Cenificam of Consent o selGinsum ror Workers Compen.
.tion,as provided for by Section 3700 of Nc LOW,Code,for But performanco of IW
work for which his permit is issued.
0 1 have and will maintain Worker's Compensation Insurance,as required by Section -
3700 of the Labor Code.for But performance of be work for which this permit is issued.
My Worker's Compensation Imumtce carrier and Policy number are:
cantor: Policy No,
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(The section necd not W completed if the Permit is for one hundmd dnllan($IMI)
or less) ,
I certify Nat in But perfom um.of be work for which this permit u issued.I shall or
employ any person in any manner an as m become subject tO be Workos'Compensation
Laws of C.1ifomia.Date
Applicant
NOTICE TO APPLICANT:If,after making this Cenifcam of Exemption,you should
Income subject to the Worker's Compensation provisions of be Labor Code,you must
0Z forthwith comply with Such prnvininm m this permit shall W minced revoked.
zO CONSTRUCTION LENDING AGENCY
(-. I herehy affirm Nn Vert is a cornu cerin lending agency for be performance of
a > the work for which this Permit H issued(Sec.3097.Civ.C.)
f37 Q I<nde,'s Nam,
Lender's Address
U C) 1 mufy Nal I have read this application and sum Nal 109 above information I$
!L H toren.I agree to comply with all city and county ondimuml,and slat¢laws relating m
0 U building construction,and hereby aothome represenutiva of Nis city to enter upon use
W ahevc-mentioned property for inspection purposes
(We)agree to Svc,indemnify end keep Wanless the City of Cupertino against
Fs r%j liebilitics,judgments.costs and cspcnscs which may in any way accrue against said City
U Z in conaequenec of the granting of this Permit.
^' APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT Issued by: Date
SOU CE REG TIONS.
fs�U Re-roofs
naure of pplicanpC c Por Dam
HAA OUS MATERIALS DISCLOSURE Type of Roof
Will Nc applicant r future building Occupant store or handle hvardous material
as defined by be Cupertino Municipal Code.Chapter 9.12.and the Health and Safety
code,Section25532(a)? All roofs shall be inspected prior to any roofing material being installed. .
0 Yee xNu
Will be applicant Or(atom buildingoccupont use equipment or dcvmea which If a roof is installed without first obtaining an inspection,I agree to remove
,coir hvafdous ser contaminants as defined by the Bay Area Air Quality Management all new materials for inspection.
District? `'
Dyes y.
Ihav,read Nch.Socuo 255O5ld5533mdcnuunder Chapmrh.95ofthe Wilding
rims noN&Safctyhawassnlom 255115,2myotsid25534.1 understand NmiflW Wilding.
dao not currently hove a tenant.Nat it u my ruponsihility to salify 109 aeupmt niche ,
mquirem,nkaw hmustbemetpriortoosuanccofaCcruf amof Occupancy^ ^� o ig ature of Applicant Date
no therixc se nam / All roof coverings to be Class "B" or better