04110047 CITY OF CUPERTINO
BUILDING DIVISION PERMIT — C®NTI2ACTdRaINFORMAT O,N Y ' -
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BUILDING ADDRESS: PERMITNO.
YQM CONSTRUCTION 04110047
q _ PERMIT ISSUE DATE
SANITARY OL NO. -
ARCHITECtENGINEER: - - ^' BUILDING PERMIT INFO
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-BLDG ELECT'.__ PLUMB MECH
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MOp LICENSED CONTRACTOR'S DECLARATION •' Ib Description
F 1 hasty affirm that I am licensed under provisions of Chapter 9(commencing O-, - - .. ..
with See, )of Division 3 of NC Business dPmfcssions Code.and my lieeom is
„ in full fa aeffeeDEMO
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Ha Lieenu Lie#,
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"ndynmyplanshib =dvpublic nrdl2
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5 OWNER.BUILDER DECLARATION
CondrON -
K a Z I hemhy.(bees that 1 1. exempt tram the Convectors i Any c Law co the
O O following mason. emit 1 ]iumn Business and marmot,
de nrm Cole:Any city m manly _
K$ Which requsuapermit re cnmsubealter,improve,dcermitt ore a siany gnedantimere
it
that heor its lzmenceumant to Me prWis usofant for such
ments Lflc.Lawdsummcm
athmhc ementnwit purstion 7Nc Of visions 3N tCamrxwri Licenselew(Chapor9 Sq. Ft. Floor Area Val va
W On M is
apt Section7")an d Br Ory is far of NC Busegad exempt Professions Cao)of
On he u exempt therefrom and Ne basis far the alleged cxempuon.Any violation of
Section 7031.5 by any applicant far a permit subjects in.applm.1 to a civil penalty of eE, - Occupancy Type
not marc than five hundred dollars($500). 3�/S Z-/�OjJ�, kJ 0
0 I,as owner of the propeny,or my employees with wages as Nei,sole coo pcnvdon,
will do the work and Me Mai is not intended or offamal rot seo(Sec.7044.Business -
Required Inspections '
and Professions Code:Th.Comrremi s License Law docs not apply man owner of - Q -
pmpcnywhobuildsofimproiourOt and.and who doessuchwork Waselforthrough his
own employees,provided that such improvement art not intended or offered for sole.If, - -
however,the building or improvement is sold within one year of completion,Ne owmr.
builder will have Ne burden of proving Out he did not build or improve for purpose of
salt.).
0 1.as owner of Ne property,am exclusively contracting with licensed contractors to
construct Ne project(Sec.7014.Business and Professions Code:)To,Conuuwra Li
cause Taw does not apply to an owner of progeny who builds or improve them rn,and, '
who comment for such projecus with a contracmrts)licensed pursuant o the Contractors
License La-
0 1 am exempt under Sec. B&P C for this mason
Owner Dam
WORKER'S COMPENSATION DECLARATION
I hereby affirm under penalty of perjury au of the following declarations:
haw and will malmain a Ccrnifimm of Consent to ulf.insum for Workers Compo,- -
mn,as provided for by Section 3740 of the tabes Codi for the pcffatmmce of the
kwork for which Nis permit is issued.
1 have and will maintain Worker's Compensation Insurance,u myuimd by Eecfion
J orthe labor Code,for Ne performance of Ne work for which this permit is issued
My Worker's Cnmpentauon Insuranm carries and Policy number am: ''r
C.O. /as Poli N 4' J'�s _
CERTIFICATE OF EXEMPTION OM WO
COMPENSATION INSURANCE
Cleo section need not becompleted!fine permit is for one hundred dollars($100) -
orless)
1 occur.Nat in he performance of the work for which Nis Permit is issued.10.11 nut
emplo;any Komrr in any mannar an as to became runnel to Me Wirdecia'CimarandAlkin
Laws of California.Dau
AppOont
NOTICE TO APPLICANT:If.after making this Certificate of Exemption,you should
become Subject in Ne Workcr's Compcmation provisions of Ne Labor Code,you must
.J Q m
fonhwith Comply with such provisions Of this Permit shall be deccd revoked.
Z� CONSTRUCTION LENDING AGENCY
[-. Iheraby aRrm that Nem is a emutmcunn lading agency res Ne perfarmamx of
CNc work fur which this permit is issued(Sce.3(197,Civ.C.)
Tal A lender's Name
Z) Lenders Addfuss
U p 1 mnify Nu T have tend this application and sum that the about information is '
F
coma,I agree m comply with all city and county ordifunces and sum laws relating to
0U building construction,and hereby authome mpmscmatiws of this city to enter upon the
r Uj Meson-d enfiuned property far irnpced n purposes
(We)agree to save,indemnify and keep harmless Me City of CLIKOM against
Hh liabilitiu,judgmcnt,costs and expertise which may in any way acemc against said City `�'
U Z in consequence of the granting of this permit.
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT Issued by: Date
SOURCE ATIONS.
A Re-roofs
Sig cadvCammem' Da¢
HAZARDOUS MATERIALS DISCLOSUR Type of Roof
Will thcappiicant or future building Occupant store or ndle husrdous diamond
as defined by the Caperton Municipal Cade.Chapter 9.11.and the Health and Safety
Cade,Section 15531(a)7 �' All roofs shall be inspected prior to any roofing material being installed.
0 Yu '
Will the applicant ar Tamm ilding oceupam use equipment or Jcvices which If a roof is installed without first obtaining an inspection,I agree to remove
e' nemfdous air mmandro rat as dcfmn d by the Bay Area Air Quality Management all new materials for inspection.
Witt?
CYcs )�Na
1 have mad Ne bmallous materials requirements under Chapter 6.95 of the Calrmo
ria Health&Safety Codc StcWm 5N15,25533M 25534.1 undcrvuM thuif lite Wilding
docs nut currently ha maggot,that it is my,eatioduchiliry to nattily the Occupant of me
m tri Must bcmet poor wOtto acertifd arQmpar¢y. Signature of Applicant Date
!y a All roof coverings to be Class"13"or better
O cr uthourcd m Dau