03120046CITY OF CUPERTINO
CONTRACTOR IN'�OTiMATI,ON'
BUILDING DIVISION PRRMIT
BUILDING ADDRESS:
4A WTNTrqPTTPZ P1
MORTON FINHILL
PERMIT NO.
03120046
ER'SNAM`/
4 C 0r_]0 --x_
PERMIT ISSUE DATE
x
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SANITARY OL NO.
ARCHITECIENGINEER:
BUILDING PERMITINFO
BLDG ELECT PLUMB MECH
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LICENSED CONTRACTOR'S DECLARATION
Job Description
p
I hereby affirm tem I am licensed under previsions of Chapter 9 (commencing
with Section 70tk)mDivision 3 of Ne Busincas and pormasions Cmintru d my license is
in full force and effect.
REVISION --IN HOUSE USE ONLY
License ClassLis. a
Dao ContractorO7�NBTd
�RMIT ISSUED/ORIG. 403010046
ARCHITECTS DECLARATION
1 understand my plans shall the used as public records
Licensed Professional
OWNER -BUILDER DECLARATION
I hereby affirm that I am exempt from the Connector's License Law for the
following mason. (Section 7031.5, Business and Professions Codc: Any city urcounty
which requires a permit to construct. Rhea improve, demolish, or repar any stmcum
prior to its issuance, also requires the applicant for such permit to file a signed statement
Contractor' License Law (Chapter H
Sq. Ft. Floor Area
Valua[i cl
that he is licensed pursuant to the provisions of Ne a
(commencing with Section 7000) of Division 3 of the Business and Professions Code) or
4 10.7
that he is exempt therefrom and the basis for me alleged exemption. Any violation of
APN Number
Occupancy Type
Section 7831.5 by any applicant for a permit subjects the applicant to a civil penalty of
not mom Than fire hundred dollars Who).
❑ 1, set owner of the property. or my employees with wages as them sole compensation,
36230023.00
Required Inspections
will do the work and One iWcti n is not intended or offered for sale (Sec. 7W. Business
and Professions Code: The Contractors License law does not apply in an owner of
propertywho builds or improves thereon, and who does such work himself or through his
ovancropinyxics, provided thauuch Improvements are nmimended oraffered forsale. If.
however, the holding or improvement is sold within ore year of,madclim, Ne owncr-
builder will have the burden of proving that he did not build or improv for purpose of
sale.).
❑ 1, as owner of the Property. am exclusively connecting wit licensed convectors to
construct the project (Sec. 7044, Business and Professions Code:) The Contractor's Li-
Cense law does not apply to an owner of property who builds OF impmvex themon, and.
�c-
O
who contracts for such projects with a contractors) licensed pursuant to the Convenor'
License Law.
❑ 1 am exempt under Sec. . B h P C for this reazon
m�/�'��y[/e Dote
-
•/ 'WO R'S CO ENSATION DECLARATION
I hereby affirm under penalty of per jury ane of the folio gdeclmations:
I have and will maintain a Contraction of Consent to self -insure for Worker'sCompen-
etion, as provided for by Section 37M of the lobar Code, for to performance of the
work for which this permit is issued.
1 have and will maintain Worker's Compensation Insurance, as requited by Section
37W of Out Libor Code, for the performance of the work for which his permit is issued.
My Workers Compensation Insuence Cartier and Policy another am:
Cartier. Palley No.:
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(This section need not be completed if the Fermin is intent, hundred dollars (SING
or [Cie.)
I cenify that.�t the PPf5rfmmance of the work for which this permit is issued. I shall not
employ any per�xlfaey manner se as to become subject to the Wed¢r5 Compensation
Laws of Calif a. D0
ApPPlicank
—
N,rgfICE TO APPLICANT: If, after making this Cenificale of Exemption, you should
a subject to the Worker's Compensation previsions of the labor Cade, you most
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rthwith comply with such provisions or this Permit shall be deemed revoked.
CONSTRUCTION LENDING AGENCY
that dem is construction lending agency Ice me performance of
I herebywhich
s
' theLe work for welch this permit is issued (Sec. 3(197. Civ. CJ
iLenders Name
�.
Lender's Address
1 certify that I have mad this application and set, Nan the above information is
women I agree to comply with all city and county ordinances and sure laws relating to
building construction, and hereby authnrim representatives of this city to enter upon the
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above-mentioned prepeny far inspection purposes
(Wt,) agree to save, indemnify and keep hormleas me City of Cupertino against
j liabilities.judgments, costs and expenses which may in any way accrue against said City
in conseyucnce of the granting Of this permit.
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON -POINT
Issued by: Date
SOURCEULATIONS. / 4,
Re -roofs
Type of Roof
Signame ApplicanVContmcmr etc
HAZARDOUS MATERIALS DISCLOSURE
dl me applicant or future building uccupant store or handle barmdous material
by me Cupertino Municipal Code. Chapter 9.12, and the Health and Safety
It,, Section 25532(x)? `All
roofs shall be inspected prior to any roofing material being installed.
DV MNu
itrefired
If a roof is installed without first obtaining an inspection, I agree [o remove
Will the aFFlicant or rruture building occupant use equipment or devices which
haaardous air contaminants a defend by the Bay Area Air Quality Management
all new materials for inspection.
District?
0 Yes fZNVn
1 have read the huMous materials tcquimmems under Chapurh.95 of the Cation.
ma Hcalm 6 SafetyCods, Sections 25585,25533 and 25534.1 understand matif the huilaing
Jocs a t currently M1aye a tenant, that it is my responsibility to notify the secupenl of the
rcyui In.wlh emnemetp rlommaneeofacenifiea or cnpanry.
Signature of Applicant Date
/ f
All roof coverings to be Class "B" or better
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