04080145 CITY OF CUPERTINO
BUILDING DIVISION PERMIT "tiCONTRACTORaINFORMATION
BUILDING ADDRESS: JM CONSTRUCTION PERMIT NO04080145
OWNER'S NAME: PERMIT ISSUE DATE
E:
SANITARY OL N0.
ARCHIT=dENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
0
L O o LICENSED CONTRACTOR'S DECLARATION Job Descri
C 1 hereby affirm del 1 am licensed u r provision of Chapter 9(commencing
<b with Secton]Ofagaf Divisom Sof the Bus and Profcasimis Code.and my liceme is MNALL
^mu, men rafh a Neffeel �e ?g 6e >6 FIRE DAMAGE REPAIR
_q z License GYM
_�, �.t,_ a, Contractor las — NOV // 2004
ARC H_MCTSDLc1*AT10N I�
yK 1 understand my plans.all he used ayRyhl c records
'LL
U BUILDING
aY I hereby affirm on 1 oat exempt from dr Cnnonnoo License Law for the
>.p O following mason. emu ft t ](131.5,Business., ,dcaum Cade:Any ciry art county
a� which requires a pcmlil m cnnslrucl,eller,imPmvc,dcmnliN,m repair any suuwent
HZi prior In its issuance,also mquios the applicant for such permit o file a signed staemem
< Nath,is licensed pursuant to the provisions ofthe Convector's LicenuLaw(Chapter 9 Sq.Ft. Floor Area gValu Icon
(commencing with Suctien]WO)of Division 3 of to Business a no Prnfessieo Code).1
E W S that he IS exempt therefrom and the boss,for tie alleged exemption.Any violation of
Section 7031.5 by any applicant for a permit subjects she applicants o a civil penalty of 3-MVft8ter00 Occupancy Type
not ream than five hundred dollar($500).
0 I u mvvo of the pmpooy,tar my employers whh wags as theta to compensation.
will do de work.and the structure is not intended or Ciliated for Sale(Sec.70M,But.
and Professions Code:The Coruselor's License Law data not apply to an owner of Required Inspections
property who builds or i m provea demon,end who does such work hi mself or through his
Own employes.pmvidsd that such improvements are not intended oroRned forsake If,
however,the building or improvement is Sold within one yeas of complcuon.she Cones.
builder will have de burden of proving that he did MI build or improve for purpose of
sale.).
0 I,o owner of the properly,am eaclusively contracting wish licensed mnuaebn to
comtmct de project(Sec. 04a.Business and Professions Code:)The Contractor's Li.
cense law does act apply to an owner of property who Wilds or impmva demon.and,
who convects for such projects with a cortractoKs)licensed pursuant in the Conua wa`3
Lies.Law.
0 1 am exempt under Sec. .B A P C for His moon
Owner Data
WORKERS COMPENSATION DECLARATION
1 barony alfinm under penalty of perjury One of the following declarations:
have and will maintain aCcNfr®e of Consent a scif-iasure for Warkcfs Compere
satian,as provided for by Section 3700 of the tabor Code,for de performance of the
work for which this permit is issued.
0 I have and will mainuln Wmace,Compensation I..,as requited by Section
3700 of de Iahm Cade,for the,performance of the work forwhich this permit is issued,
My Workers Compensation loan...sortie,and Policy number em:
C/+mc ST4�E FJ NE% Poliry No.: ^ 03D C3
y CERTIFICATE OF EMPTIONFROM ORKERS'
COMPENSATION INSU
—' (INS satian reed not W completed B lie Permit isrmanc hundmAdollars(5100)
or less.) I
1 eco fy that in de performance of the work for which this Permit is issued,I shall not
employ any person in any manner so as an hccomcwbjOel to the Worker'Compensation
Laws of California.Dae
Applicant
NOTICE TO APPLICANT:If,after making this Cenificam or Exemption,you should
barome subject in due worker's Compensation provisions Of the labor Code.you most
00 fo,hwith comply with such Provisions Cr this Permit shall W clamed revoked.
Z y CONSTRUCTION LENDING AGENCY
[�. 1 hereby ern that then 4 a Coowction lending agency Tar de performance of
IY> ft work for which this permit u issued(Sec.3041.Civ.C.)
I]]Q Lendcr's Name
6. Lenders Addess
U C) I certify,that I have read this application and also,dust the above mfomstiun u
LU f••' correct.1 agree to comply with all ciry and county Ordinances and sure laws relating Ire
DU building construction,and hereby authorize mpresenutim ofthis city to enter upon the
r[37 aneve-mentioned property for iopccuon purposes.
(We)agree to save,indemnify and keep harnleu the City of Cupertino against
F N IinbilideYjudgmcntsp
,costs and expenses which may in any way aeuc againstaaid Ctry
U z in consequence of the Sowing of His Permit,
APPLICANT UNPERSTAN AND WILL COMPLY WITH ALL NON-POINT Issued by: Date
SOURCE TIONS.
Re-roofs
SlipusumentAPplicand/Codwaretor Dae Type Of Roof
HAZARDOUS MATERIALS DISCLS)SURE
Will the applicant or future building Occupant store or handle hanrdous maerial
as defined by the Cupenino Municipal Code.Chepef 9.13,and the Heald and Safety
Cade.Session 25532(.)+ All roofs shall be inspected prior to any roofing material being installed.
❑Y s �Mo
OWill de applicant or future building Occupant use equipment or devices which If a roof is installed without firs[obtaining an inspection,I agree to remove
il haurdna.air cm Wom;n u d,Ead by the Bay Area Air Quality Management all new materials for inspection.
District?
[3 yes Nu
I have mad the hvardsws materials equimments under Chapter 6.95 of the Caller.
ria He. kSawy code.Sections 25505.25533 and 25534.1 understood that ifthe Wilding
dt hove nanLthalitumymspmmlbililymnutilythcacupmtofthe
he �k on met poor IninuanmafaCertificate orOccupancy. Signature of Applicant Date
Owner or aamoda ascot ' v ate All roof coverings to be Class"B"or better