04010019CITY OF CUPERTINO
°-
BUILDING DIVISION PERMIT
CONTRACTOR INIFORAATION. '
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BUILDING ADDRESS:
CONIFER CONSTRUCTION
PERMITNO04010019
OWNER'S NAME
PLRMrt ISEUE GATE
SANITARY NO. CONTROL NO.
ARCII[TECTIENGINEER:
BUILDING PERMIT INFO
BLDG ELECT PLUMB MPC11
0 0 0 0
LICENSED DECLARATION
TORmoil,
Job Description
, I a. liYned
affirm I am licensed under j of Chapter 9
P
nd Proons
ion 0
my hear. 1,
with Sectionnor' of Division Sof the Business and Profession Cnde, antl my livens ix
ivi
r 11 .I area`fTe GB7Yz—
REVISION --RAFTER COLLECTER
loan,in
License CP' Lic. a
,
°aa GenumC1Of
ORIG. 403070224
ARCHITECTS DECLARATION
1 undccaand on, plans fiat] 1¢ used ax p.hire records
Licensed Professional
OWNER -BUILDER DECLARATION
I hereby affirm'bat I am assists from the Commetor's License law for the
following reason. (Section 7031.5, Business and Profc.aions Code: Any city sir roomy
which requires a permit m construct. alter, improve, Jcmnlixh. sir fired, any structure
prior to its issuanse, also ruptures the applicant for such permit to rile a signed slmement
that he is licensed mrsoanno the pmvisinnx of thcCommebari Liecnsc taw(Chap(cr 9
Sq. Ft. Floor Ai ea
Va�ytb)o 000
(commencing wish Section 7000) of Division 3 of the Business and ProfessionsCods) or
Nal he is esempl therefrom and the basis far the alleged toandui.n. Any violation of
ApN Number
ane
Occupancy Type
Section 7031.5 by any applicants for aparmit subjects she applicant to a civil Penally of
not more man five hundred dollars ($500).
P Y
01, as owner or she pmpcny, of my employees with wages res their sole compensation,
36206037.00
will do she work, end the xwnure 41
is not intended or offered for sale (Sec. 70, Business
Required Inspections
and Pmfcssinns Codic The Contractor's License Law doss not apply to an owner of
prapeny who hm]sB sir improves thereon, and who does such work himself or through his
own employees, pnwldcit that such improvements arc is, intended nrnffered far s Ic.IC
hnweveq he building or improvement is sold within one year of completion, she owner
builder will have the burden of proving but he did Out Wild os improve far purr.. of
sale.).
g 1, as owner of she property, am exclusively connecting with licensed contractors to
countries the praiser (Sec. 7144, Business and Profusions Code:) The Convector's Li.
Neuron and
come whocoawricessolapply to ojects ishawner o(pr.peny who sed pursuant to
whocontractsLacts for such projects with a e.mncmr(s) licensed pursuant Io the C.nveaofs
/
LICCvu Law.
❑lam ucmps under See ,B&PCfor this rtuon
Data
WORKER'S COMPENSATION DECLARATION
I hereby affirm under penally of perjury one of the following declarations:
have and will maintain a Curti ficam of Consent self -insure for Worker's Cnmpen
t m provided for by Section 3700 of she Labor Cnde, for the peformance of the
1woe,
(os which this permil is issued.
have antl will maintain Worker's Compensation Insurance, as required by Schon
of the labor Code, for the performance.(,he work for which this permit is issued.
orker's Compensation Insurance carrier antl Policy number art:
er. Policy No.: _
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(This actions need not he completed if the Permit is Tnronc hundred dollars (s IIX)
Ices.)
1 certify isms in the performance of the work for which this Permit is iman, I shall not
employ.my person in any manner s s u In become subject to she Worked Compensation
haws relCalifornia. Date
Applicant
NOTICE TO APPLICANT: If, after making this Ccni0cmc of Exemption, you should
become subject to the worker's Compenmlian provisions of the labor Cnde, you must
forthwith comply with such previsions or this Perm i Ishall W deemed revoked.
CONSTRUCTION LENDING AGENCY
1 hereby affirm that there is a construction lending agency f sir she performance of
W work for which this tennis is issued (Sec. 3097, Civ. CJ
Lender's Namc
Lender's Address
I comfy Nat I have read this application and nate that she above information is
Torted. 1 agree to comply with all city and county ordinances and state laws relating to
building cnnsvuesion, and hcnhy aathmim representatives Or his city m Omar upon the
above-mentioned property for inspection Purposes.
(We) agree to save, indemnify and keep harmless the City a( Cuporrom against
liabilitietjudgmem B. costs and expenses which may in any way accrue against said City
in consequence of she granting of this permit.
Z04y/
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APPLICANT LINGERS TAN AND WIL COMPLY WITH ALL NON -POINT
Issued by: Date
SOUgQ(i REGULATIO .�
-
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Type of Roof
si gnalushoe.f Appctanvenntacmr DataRe-roofs
HAZARDOUS MATERIALS DISCLOSURE
Will she applicant or future building Occupant some or handle haxen ous material
as defined by she Cupertino Municipal Code. Chapter 9.12, and the Health and Safety
C.Je, Section 25532(')?
All roofs shall be inspected to any roofing material being installed:
❑Yen 5? No
prior
If a roof is installed without first obtaining an inspection, I agree to remove
Will sire applicant or future building oectiman use equipment or devices which
bazmdous air r.nmminants an. skiiord by she nay Arca Air Quality Management
all new materials for inspection.
st?
El Yes [X NO
I�K
I have mad the haardnus materials regm onsiams under Chapter 6 95 of she Cables-
ealth B Safely Cook. Secnom 255(15, 25533 and 25534.1 understand the, if dm building
one.l, have a tenon I it is my responsihilily to noJly nhc tacupanl of she
hich most Iprior minn c sir a Ccrdficaa of Occupan
Signature of Applicant Date
/� ��Owner
All roof coverings to be Class "B" or better
agent
to authoriv.cd Dan