00090048CITY OF CUPERTINO
CONTRACTOR INFORMATION:
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BUILDING DIVISION PERMIT
BUILDING ADDRESS:
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PER II'I'NO,
OWNER'S NA 1& -INFjffjTe-EP
APPLICATION SUB DATE _
PHorvr::CIJRERTINO GRT I
SANITARY NO. CONTROL NO.
RCHITHCf/ENGI,NEER:
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BUILDING PERMIT INFO
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BLDG ELECT PLUMB MECH
LICENSED CONTRACTOR'S DECLARAI ON
Job Description
1 hereby affirm uml 1 ane heeneed and....... visions of Chapter 9 (commencing
iwith Section 7") of Division 3 of the Business and Professions Cole, and my license
s in fun f..ac and art
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License Cm„ �R�- l.fe.« 410 2
Date —g ter 1- —
- INSTALLATIO OF 'SIGNS
S DOI
Ee 5 UGCLARAT
Ar,
I onhall li
el.r W mY Plane hall he lieda, pnhllc records
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Licensed Professional
OWNERBUILDER DECLARATION
1 hemby effort thin 1 ma exempt from the Contractor's License law far the
following reason. (Section 7031., Business and Professions Code: Any city or county
which require, a permit to enmvuc6 alte, impnwe, dearmish, to repair any structure
prior to it, iamunce, at... rcgnb'e, the upplicunt u—.6 perming file.. sigmod smtcrnant
Ft. Floor Area
� Valuation
lost lie is licensed pursuent it) the provisituoul mc Comerei.r, Li,,a,e Love (Clarinet 1)Sq.
(commencing with Section 11Xgp of Divl,fan 3 oI'the Itu,iness and Professions Calm
or that he is exempt therefrom and the basis for the alleged exemption. Any violation
of Section 7031.5 by any, applicant for a pemnit sub the applicant m v civil penalty
.forma. .ban feet, anj�f[�e��ty�w1 ( oB
APN Number
Occupancy ype
❑I, isowe"It F"4 to ylRMycmpTyce�lh wage, as their sole compensation,
will do the work, and tlm xwcturc Is Bat Inwn j r Offen" for suit, (See. 7(Wq.
Business and Prfessians Cflj TIW cfYnAlilacnense Law Jnn, all aPPlr m an
owner
ow of Ptolemy Who it rate. t/eiiii A d who does such wank himself
.' equired Inspections
or his own em .. pronde l that such improvements an nor intended aro
offered for sale. ILow
hever, the building or improvement is sold within one year of
101 — FOUNDATION
completion, the owner-tvniI I w'I f proving that he did not Wild or
improveto"trpacut" ` ING
103 — LIFER
Ed1, as owner of the propeGrty.y. Inn exclusively eontmning with licensed carlemlors to
.
104 — REBAR
emnxtruel the project (See. 70,4. Business and Prfe„iam Code:) The Cadmnaf',
105 — ANCHOR BOLTS
Licenu m law Joel not apply on owner of PrePeny who builds or imprmres thereon,
and wbo contracts for such projects with a contraiourl licensed pursuant to the
304 — ROUGH ELECTRICAL
Contmnnr,ueenselaw.
111 am exempt under Sec. B & P C far this .,or
-505 — FINAL ELECTRICAL
Owner
— FINAL PUBLIC WORKS
WORKER'S COMPENSA'1']ON DECLARATION
.514
I hereby affirm under Penalty of perjury one of the following declarations:
❑ 1 have and will maintain a Certificate m1Consent it, self -insure for Worker',
rmpenendon, a4 lmvidrd for by Section 3701 of the Labor Code, for the
-rfnrrunce it the work tot which this permli i, i.s,ue l
❑ 1 have and will maintain Worker's Compensation Insurance, as requited by Section
3100 of the Labor Cale, for the performance of the wink for which this pernit is
issuedm. My Wmkce, Compensation hea ee carrier and Policy number arc:
��^ ^
Crricr. Policy No.:
L�
C17RTIFICNI'I ON OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
a
OCT O
�! 1
(This section need not tic complded if the Permit is for one handled dollars
� 2001
(Slap or lea.)
1 cenlfy that in the Penorm Ice of the work for which this peril is issued. 1
SUIL.D, s
,hall nal crudity any..anon In any manner sit ns to become ,uMeet m the Workers'
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ciat'notame laws of C.1dorolm Date
Applicant
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NOTICE TO APPLICANT: IL after making this Ccnifcme of Exnnptinn, you should
b¢ome nu the of the LaMar CNG, you mint
Compensation permit
complysuch pr shall
forthwith comply with snot Provisions or this permit shallGdeemed revoked.
CONST RUCTION LENDING AGENCY
c� \
I hereby air ont Ihal there is a imer hou lending agency to the peniormnce
of me weak for which this permit is issued (Sec. 3097, Civ. C.)
er
Lender's Name
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Lender's AW.",
1p1o
1 certify that I have mud this application and state than the above information i,
V
om I nce to comply with all city and county oNmet d Btu's law, mlating
totgr
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bu'ddiog con,tmmmn, and hereby aur herim ecpre,cmmive, aro Ont' Gay tomer up..n
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the alxwomentioned property farm,,Oian purposes.
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(We) egmc to saves indemnify and keep hu ntle,, the City of Cupci ino against
liabilities, judgments, costs and expenses which may in any way seems, against said
City in consequence of the granting of this permit.
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON -POINT
SOURCE REGULATIONS.
ISSIedb y: Date
Signmme of AP11hennUCmaorooi Date
Re -roofs
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future building occupant store or handle haa:udmus trarniul
Type of Roof
vs defined by the Cupertino Municipal Cale. Chapter 9.12, and the Health and Safny
Code, tion 2553200:'
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Yth Cl No
All roofs shall be inspected, prior to any roofing material being installed.
Will the applicant or fuume biddingtecustmt use cgmdjauentnr devices which
If a roof is installed without first obtaining an inspection, I agree to remove
emit haanrdo., air coal ...m Its us defined by the Day Area Air Qualhy Management
District^
all new materials for inspection. Applicant understands and will comply with
Jk7tm °No
all non -point source regulations.
1 have read the hmmtl..us materials requimamna under Chapter 6.95 of the
Ili fnrnm Ihard, & Safety Code, Sections 25511.5, 25533 and 25534 1 nndersland thin
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if the bu ildi ngdoes not cumally leave a tenant. dun his my mspnt to roll fy the
re
occupem of the rhe Ili mem, which mus he con prior m »un c of ifmam of
OccupancX/
9�i
Signature of Applicant Date
All be Class "6" better
Own�taralt t" n, Da,
roof coverings to or
i/ OFFICE