04040100 CITY OF CUPERTINO �"""" "'' Ctr
BUILDING DIVISION PERMIT C�ONTRACTORIN FORMATIONN
BUILDINGADDRESS: CUPERTINO CONSTRUCTION INC PERMITN004040100
R'S NAME: PERMIT ISSUE DATE
DANNY LEE '115
ONE: SANITARY O. OL NO.
ARCHITECDENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
�Op LICENSED CONTRACTOR'S DECLARATION - - Job Description
u I hcseby off.that 1 am lieamcd under pmvirions of Chapter 9(commencing
win Section?MB)of Division 3 of the Bu dins.and Pmfcuio re Coda,and my license is
^teaimm�foeaanee ec REVISION--IN HOUSE USE ONLY
b&z License Class lie.N
Date cmiloctar NO NEW PERMIT ISSUED/ORIG. #03020096
ARCHITECT-S DECLARATION
a I undcrsund my plana shall he moth as public records
3ra
3rm LkcnttO Professional
5 OWNER-BUILDER DECLARATION
1 hereat.(Sinn o n I em exempt from the Communes o License Taw forco nc
yp o following msson.(Section mosam, i, loo. and Pmfcssium Cade:Any city nr rummy
$ a, requires a�iy w cmmmca alma,impmte.OcmnlW,or repair any smunure
prior m ire ipeueecc.also mquirpe Ne applicant for such permit w f Ie a signed statement Valuation
thatheislimmied pursuant to Ne pmvisiam of nc Conuacmr'S License law(Chepter9 Sq.Ft. Floor Area $0
K�D (cam mencingwith Secfrousaddr Beed,nl da,
eslandon.Araya Code)of
Dy$ Natio Is campy thme(mm and or aper for ebe alkgW eumant to Any violation of
Section 7D31.5 by sub applicant for apermiy Subjects the applicant to acmti penalty of ppN Number Occupancy Type
nut mart than Esc hundred dollars,(Woo). 35701017 . 00
Lo it worof and
pmpruct r is not emPloyw winwageu Heir Sole compenution,
will dodrework end Neswnumrnmet'nlended crons awdoswset.
pplyUBH,Business Required Inspections
and property
who bu Code:The CanmttmYs Liana Taw dors not apply U.,t owear of q P
.a employ b, ds pmol improv n hapre.d who sub mark work himueund Waugh his
own employees,provided that such ire,I,and rata are noti.of c orolfuW for ala 1L
anild., .Nca.ftorimprovementis soldwididno,eyearofmopme.forthepwear-
builder will luv<ek NrNcn of proving that k did no,build or improve for purpose of
tile.).
1.u caner of the Mistily.am cxcbexvely conercling with limmoed ronmeton Or
Ouct Ne project(Sec.7044.Basins and Prefesdeas Code:)The Con ranor's U. S
came law dors not apply man owner of pmpeny who builds of improves d ertan,ad.
who contracts for such pmjeas with a cantramor(U lim=d pursmam m the O mrcmrs
Lken m Law.
❑lam Lae oder Sec ,p .B&PCfw yhb won
e\ �_
Da¢ i0
9 WORKER'S COp1 ENSATION OECLARATIO
1 hereby aRrm under penalty of perjury one 0`!d1_uwing decluWoru:
1 have and will maintain a CcNfcnte of Consent m self-insure for Wof esCompcn-
sation,as provided for by Section 3700 of do,Labor Code fm the performance of the
work for which this permit is issued.
❑1 have and will maintain Workers Compensation Insurance,pe tegal.d by Section
3100 of the Labor Code,for rte penrofmas.of de work for which this permit is Marc.
My Work es Compensation Inaururce caricr and Policy number art:
Camra. Policy No.:
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
OTrseNm head Out he complcied lithe permit is for one hundreddollars(SIM)
Or kms)
1 mnify Net in the pnform m.of the work for which nix permit is issued,I shall not
employ any person in any mannerao so in become subject in she Worteri Comptuanit on
Laws of California.Data
Applicant
NOTICE TO APPLICANT:If,after making this Certificate of Exemption,you Would
become Subject to the wankel s Compensation previsions,of one Labor code,you mon
.^JZ forthwith comply with such prnvisions or this permit shall he deemed rewrked.
Z O CONSrBUCTION LENDING AGENCY
[-. 1 hereby Affirm our there is a consmuction lending agency for Nc perfurmancc of
a 7 the wart for which Nr permit is issued(Sm.309?,Civ.C.)
W Q IandcYS Name
C. Lender's Address
U C) I certify dol 1 hsa L read this application and sole Nu he about information it
W cancer.1 agru to comply with all city and county ordinances and sate laws relaying m
U builtlingconswee to and hereby eunodumpr hasent csthis city tocnteropus r-9-inthe
r W above-mentioned pmlerty for insPection fur pores
es ju agrees,ase,indemnify and keep may
in an Bee City of Cupenst against
fq liabilidu,judgmens,.cosm and eaperysee which rear in any way accrve against'said Gip K410_�v UZ oronaquexeaf the granting of this permit Date
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NOWPOINT Issued by:
SOURC ULATIONS.
—� Re-roofs
gnuurc ppfranJCanmum Date
HAZARD9S MATERIALS DISCLOSURE Type of Roof
Will the applicant or for.building Oceupmt amre or handle hauNom material
pe defined by Be CupMomd Municipal Code.Chapter 9.17.and the Health and Safety
c.Section 75537(aj? u All roofs shall be inspected prior to any roofing material being installed.
0y.
If a roof is installed without first obtaining an inspection,I agree to remove
Will the applicant or future building mcupant ure equipment or devices which
mit hazardous air contaminants as defined by tie Bay Area Air Quality Management all new materials for inspection.
District?
❑Yea @No
I have mad the Wardew materials mquirtmew under Chapter&95 of de Glifoo
nia Hcnln k SafelyCodc,ScNom 25505.75533 and 75S34.I undcrumd nnirft building
don rent cu ntly h.w o tenant,Nat it'r my mspomibiliry IO nouly du MCmm t of the
require=is which re mnpnormissuanaafaCcmf' OfOccupancy.
5 /'91 Signature of Applicant Date
All roof coverings to be Class"B"or better
Owner OnuNOriutl agent �--'� Dale