00100080 k CITY OF CUPERTINO t
BUILDING DIVISION PERMIT CONTRACTOR INFORMATION:
BUILDINGAUDIT : 11T.11.
OWNER'SNAMUMCNULTY DANIEL A AND AR ENE D 1725 RUDUEHb HVI= APPLICAI]ON SIA /2z00_
ONE: (408) 487-0390 SANITARY NO. CONTROL NO.
C m z ANCHITECfRiNG1NEER: ` BUILDING PERMIT INTO
s O - BLDG ELECT PLUMB ME
Q z f_I Li—I 7 1 -7
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LICENSED CONTRACTOR'S DECLARATION Job Descri tionloor
Z0� IhercM1y uftinn that l sen licensed under provisions of Chapter 9(cmmmencing FURNACE p
pmt-w with Section 700po1 Division 3nf In.Ilmirw,and Prefesaion,Code,and my license
ix in Lu -arse unJ t.
owl Lie eClaxty 4 Lie.» reau,w F01��3kf�[�D
w 3 w m;_ s DECLAr
ARCndlhe le DECLARATION
I nndanlumA my pbmssh�ll he uncJ as Public rocnrcl ��� � � 20 U1
5� y
I+1 O Licensed l'mibnsia ral .
OWNBIi-BUILDER DECLARATION
w I herchy allon thus 1 nm exc,a,t from the Contralto's License Law In the
F3C follnwinyreason.ISe11inn7031.5.Im,iness and Professions Cale:Any city in county BUILDING
LA
O which requires a lurnut to conB
n
uct,alter,improve,demolish,or repair any structure
i 3 W Prior to it,"wince.nLm regnireslhe upplemn fn...ch"uniunfileasi6ned'unewin
that he is ncene,dpra,9anito hepookio.ofthe Comrvcmr.License Law(Chapter 9 Sq. Ft. Floor Area ValuadoWOO
m
(comencing wtth Section 70X0)of Divisina 3 of the Business and Profesions Code) s
or that he is exempt therefrom and the basis for the alleged exemption.Any violation '
of Semina 7031.5 by any nPplicent for a permit subject,the applioam In a civil penalty
ofa.,moremtnFire hundred dollars($50n). APN360tirl.024. 00 - Occupancy Type
❑1,as owner of the progeny,or my employees with rages as their sole compensation,
all do the ones,and the structure is not intended or uBemd for .It (Sec.7044,
Business and Profession,Code:Toe contractors License Law does but apply to an 301 — R(RdQlil-edP nkW ibhlG
nt,de,ofpn,,dyWho Wild,ttimpmvestheretn,and wnoduesinch wml,him,d( 30" — ROUGH MECHANICAL
nr through his own cmpinyces.gnoided tbar such imro
pvment
es are nm intended or �r
offered foo sale.If,howeve,the building or improvement is sold within one year of
completion.the owneolm ider wil l ha,c the burden of proving that he did not build or 304 — ROUGH. ELECTRICAL
imgrove forgurfn„cof sale.)' `i05 — FINAL ELECTRTCAL
❑1.a, ,,actofineproperty,arae,ulteivelycontmmngisanliowicontinuousb' 507 — ' FINAL PLUMBING
construct the project(See 7044.Business and Professions Cade:)The Contractor's
License Law dues sen appy m an none,of Irela dy who bairn,or imp c,theater. 508 — FINAL MECHAN I CRL
and who a uma,i, lin such projects with a a,mmut o)licensed ponuunt n,the
Conna,mo"License law,
❑lamcxmnpt under Ser. ,B&PC for Ili.rcusnt
_ Owner Date
a WORKER'S COMPENSATION DECLARATION 1
I barehy union under pmmlly of perjury one of the fallmving decbmnien,
I have and will maintain a Ccr iGcate of Consent to self-insure for Worker's -
Cnntpanmlion, as provided fin by Section 3700 of the Lima, Code, for the
pc ll...m uc iu the work R,r which this permit is issued.
❑I have mrd will maintain Workers Compensation Insurance,as requlrcd by Section
370)of the labor Code,for the ptrformance of the work for which this permit is '
.sued Sly Worker',Compensation Insurance carrier and Policy number we:
Car Df h?UQs( Policy No.: r M30131
CERTIFICATION OF F.XEMP`pION FROM WORKERS' '
COMPENSATION INSURANCE
(This section need not he completed if the Permit is for one hundred dollar,
(Sl/q)ter let,.)
I cent that in the pctimmance of the wok fur which this permit is issued.1
shall not employ any person in any manner.so as in became subject to the Workers
Compensation Law'..,of California.Date '
Applicant .
NOTICF.TO APPLICANT:IL after making this Certificate of Exemption,you should
Q 0 Mcome suhjecnn the Worker's Compensation previsions of the Labor Code,you most
fon ream comply with such prr,kiotw no this permit shall W deemed revoked. .,
z ..
F" CONSTRUCTION LENDING AGENCY
Irk lot nfhul,Nut dam iss ttlocu(Sc,nn lending agency far Inc pe,in nnnnm
W of the work Im which Ibis pennh Is Issued(g 3897.Cit.CJ
z Lendr's Name
bendeers Address - .
V 1 cenit'y that I have rued Ibis opplicmma and state thin the above information is
correct.I agree to comply with all city and county ordinances and sure laws relating
C f) rohuildingctnstrador,and herchy umhnria reprceemativea of this city m enter upon -
ry the'uhnvo-menrt ned pmpeny for inspection Furrows.
>1ly 1e'eingaoe turns,indemnify a ad keep harmless.the City of Cupertino aguia,l
liabilities h es,juduarcu s,cost,and expenses which may in any way accrue against said
C.7 Z t consequence of the gre of this pennil.
SO u1CANTU I T D WILL COMPLY WITH ALL NON PONT 'Issued by: Date
Sib awenl'AgdWa i(ontmnnr ate — Re-roofs
IIAFARDOUS MATERIALS DISCLOSURE
Will the agPlteam of fumm building occupant store or handle ba asims mmerial Type of R f
as defined by the Cupeninn Municipal Code.Claude,9.12,and the Health and Safety
Code,Section 25532101^
ID Ye, 0 N All roofs shall be inspected prior to any roofing material being installed.
Will the applicant or future building occupant use equipment or this ices which If a roof is installed without first obtaining an inspection, I agree to remove
,not notorious wr contaminants m defined by the Bay Area Air Quality Management
)imfim^ all new materials for inspection. Applicant understands and will comply with
0 YC4 ElNo all non-point source regulations.
I have read the hmardous materials requirements under Chapter 6.95 of the
California Ilcnhh&Safmy Code,Sections 25505,25533 end 25534.1 and....cordial '
If the hullding does nal cmrcntly have a tenant,that it is my reacrusibliily to rntify the
or
en nor of the atlmrw ear ''h nmnt n p
be serior to issuance of s Cenifiene of
O q'"ney' r Signature of Applicant Date
i rvncrol`a,mmdred age,,, -, - Dare All roof coverings to be Class "B" or better