00060120 CITY OF CUPERTINO .
non.mNG DIVISION ,t PERMIT CONTRACTOR INFORMATION:
BUILDINGAI)I]j354 IMPERIAL AV PERMITNC000r,0120
OWNER'SN"MES YEH. APPLICATI0 Uj1TB(f /2000
PHONE: SANITARY NO. -CONTROL NO,
MOZO ARCHI'I ECIMNGINEER: n BUILDING PERMIT INFOi
kL"x BLDG IiLECT PLUMB MECII
O I� I� TTI I_I
,6�
FF G LICENSED CONTRACTORS DECLARATION .lob Descrl tion
Z z 1 hereby affirm a th I I n licensed J provisions of Chapter 9(commencing - p
HyCtooats fenitennro- ' 9 nbeStr dP mssime,Cnde,atenyf i DEMO
4 full fore'and dro".
5 z a.3 a is
m icense ClassLic,tr t
3 a N Dem Contractor '
F O ARCHITECT'S DECLARATION ,
1 undersmnd my plam.hall he teed es public records
dnso
6� '
w 5 o O Licensed Professional -
ce OWNER-BUILDER DECLARATION
1 hereby anh m Nal I um uscone feat IM1e Cmand anr's Liernse Law for I)to
k]? following rearm.(Section 7031.5.Basin...and Pmlfic,,oma Code Any city nr county '
F x p which require'a permit to mngraf eller,improve;denmli,h, a repair any emucmae ..
dEm n
prioollskmq
issuance,vlsn nrqulresthe vyplicamfor such permit m file as96ncJ xlatemenl
dea_ 'herbals licensed pursuant hire pookiensot theContracurall-icanse Lrox(Chrupwri) .. Sq. Ft. Floor Area
(commencing with Section 7000)of Division 3 si Business and Pmfessionv Code) - _
on that he is exempt themfmm and the basis for Iho ullegcd axempfmn.Any emotion
of Section 70315 by any applleunt neonatal,objects the appllcam to a civil poualty
of no,mom Nan lisp huodreddollats(550o). Asf94`9WI(3. 00 Occupancy Type .
1 of the proper, y employeeswlh wages as their le i,eareparsafire,
I da,the wok.and the.I I iduard,cl lled f . l (See 7044,
Biespies and Profession,Code The Convenor 1'cnc Law des a,,,applyl an NO A.r'LSIGN q`11VbFCf-.I MVS
owner of property Who builds r npnxes there u.and who does such work himself
or through his awn employees.provided that such intprovemems are not intended(ir
offered for sola.If,however,the huildmg or improvement is sold within one year of
impletion,the owner-builder will have the burden of proving that he did not build or -
improve for pnlpose of sole.). -
❑1,as owner of the property,at,,marlesi,,ly can,medng wlN]feet.W conuocmrs to - -
construct IM1e project(See 7044,Business and Professions Coda:)The Contr'actor's
License Law does not apply to an owner of property who builds or improves thereon, '
and who contracts for such projects with a contractor(s)licensed pursoteu to the -
Connector's License Law. _
❑I ten exuinpt un Sec. R k P C for this reason ,
Owner -
00
W KER'S COMPDate 3N DE L RATION• - -
I hereby affirm under penally of perjury one of the following doclaindotw'. - 2
❑ 1 haveand will t timid a ciatmerm of Consent m self-insure for Wod .9
ar'
Compenntion, as provided for by Section 3700 of the Labor Codq.lor the
performance of the work for which this pe rrin is issued. -
❑I have anA will nsaimain Worker's Compensation Insnrunce,us secure
ii by Section -
391X1 of the Labor Code,for the Eciformucaue of,he work For which,his pencil Iv
sued.My Workers Compaination Insurance currier and Policy nhmher rue:
s
Carrier: Palter Nu.:
CERTIFICATION OF EXEMPTION FROM WORKERS' '•COMPENSATION INSURANCE .
(This section need not he completed it he permit is for one hundred dollop ,.
(5100)or less.) j •. -
I certify that in the performance of the work for which this permit Is issued.I
shall not employ any person in any manner so as to becmnc subject to the Workers' '
Compression Lens of Callfornie.Date
Applicant
NOTICE TO APPLICANT.If.after making this Cenifichcof F,sm ion,you should -
become wade,to the Warked
s Compensation provisions of the Iaran Cedq you mus,
Q O forthwith comply with such provisions or per shall be deemed revoked
z r _
H CONSTRUCTION LENDING AGENCY
a 1 herebyaffirmthis Nem iso coned Sad, lending agency for the performance
W of the work for which this pencil is Issued(Scq 3099.Cr,CJ
Lender's
Name
z Lender's Address '
V 0 1 certify the,I have road this real kation and vtme the he above information is
LL
E. "rrom 1 agree m comply with ell city and county ord i encs and mote laws relating-
f..) ,a building consumed. ,and thereby rcalnire representatives of this city m enter upon - r r
'y r� the shove-mcn,ioned property tiro inspection'purposIts
. -
Fy G (Wa)agree to save.'indemnify and keep hannlas the City of Cupertino against 0n
r Vl TiahlEdes,judgments,cosy aid expenses Which any in any way acerae agaim,said
V z City In consequence of the granting of this permit.
APPLICANT UNDERSTANDS AND WI .COMPLY WITH ALL NON-POINT Issued b Date i+
SOURCE REGULATIONS. Y•
Signature of npplicaneeantracom Date 'Re-roofs .
HAZARDOUS MATERIA S DISCLOSURE
Will the applicant or future huildmgocculantnlure or handle hoards,mverial Type of Roof t'
2 definad by Iho Cupertino Mtmicipul Cala,Chapter 9.12,rod the Health and Safety _ _ -
Coale.Section 25532(u)'! s
El yesxNo
All roofs shall be inspected prior to any roofing material'being installed.
Wil the applicant or future building occupant use equpplein or devices which If a roof is installed without first obtaining an inspection, I agree to remove
nmtamin
lous air conurs m ndefined by the Bay Area Air Quality Mvnegement
Dmi,hrisielcP - - all new materials for inspection. Applicant understands and will comply-,with
EI Yes JQ"° all non-point source regulations.
1 arve mad the budardrous materialsI I d Chapter 695 of the
Coldermic Health lth k Safety ty C d Sections 25505 25539 and 25594.1 understrard that
If1b,houldid,Fees of rearruptlyhamounts thtl- y p 'ludia,ue,nindythe
occupant of,he requirements which must be met prior 10 issuance of a Certiffiche of
Occupancy. - - -
�_f Signature of Applicant Date
owner.1audmarlend.,cut Date All roof coverings to be Class `B" or better