04060008 F.0
TY OF CUPERTINO
BUILDING DIVISION PERMIT GONTRACT'OR�INI+0�.tNIATOIV"�_
DING ADDRESS: JAHAN CONSTRUCTION PERMITNG04'060008
6ER'SNAME: PERMIT I%
TIM
TIM Sc VISHAKHA STEIN 200 BURNET
1 E: SANITARY NO. CONTROL NO.
(408) 782-3102
ARCHIIECTTNGINEER: BUILDING PERMIT INTO,
BLDG ELECT PLUMB MECH
uoo LICENSED CONTRACTOR'S DECLARATION
1 bcrcby affirm Nat I me themed under m,iaimo of Chapter 9(commencing Job Description
with Secti 7 )mf Di .Mm3of Neo sr a OProfeuiom Cotle.and my license is
_� mmRfore riot«L REVISION-VENTING DETAILS (/
,0:5 LI ac class LIc.N
:] SEE ORIG PERMIT 404050036 \
Dem fit,
/ ARCHITECT'S DEC ATION
u,)35 I under an my plain shell Mused u pontic records (IN HOUSE ONLY)
t C n
Licensed P.by.nal
.� 3 OatIam cUILOER DECLARATION 1�
f 1 Wrtny alum that 1 . exempt from the,Contractors License Law for 1W \�\
p0 f.11mving..on.(Swell 703 .3,Business and Pofrssium Cade:Any city or county v
$ when rtyuina•permit
to construct,alar,improve,demolish.at repair any structure
-zy prior m its issuance.also requires the applicant foruch permit m file a signed statement
< tltatMulicevcdpuruanttoNcpmvi9omafthcContfacmr'slucvci�w(Clupmr9 Sq. Ft.Floor Area Valuation
zF$ (commencing with Section 7000)of Division 3nf the Buainevand Prarassinm CMe)M
y�
that he is attempt theterrom and the,bub for Ne alleged e.mpdon.Any violation of 0
Section 7031.5 by any applicant for permit subjects the applicant to a civil penalty of APN Number Occupancy e
not mart Nan Eve hundred dollars(SSW). ! P Y '7 Ty P
❑I,as owner ofthe property,or my employced with wages as their into compensation,
will do the workand theswc.m Is not intended oroffe.dr Wank(SAO.7W,Busineu ,
and Profe.im.Cade:The Oonmeto,,Lt..law dao.1 apply m an owner or Required Inspections
property who builds or improves dteroon,end who does such work himself o r through his
own employees.provided that Such improvemena are notintended oroRaed forte.if.
nawever.Ne building or improvement is sold within one year of compledon,Ne owner.
builder will have lie burden of proving that W did not build or improve for purpose of
tie.).
❑I,As Owner of the property,am exclusively contracting with licensed contractors to
camtrat Ne pmjem(Sec.7044,Business and Proreadans Code:)The Contractors Li.
cense Law does not apply to an owner of property who Wilds or improves desmon,tad
who contacts for such pmjecu with a conmemr(s)licensed pursuant to the Conuumtoes
License law.
❑lemaemplunder Sec ,BkPCforthismuon
1'37010of
r Dem
WORKER'S COMPENSATION DECLARATION
I hereby of rad under mostly of perjury one of Me following decimations:
ave and will mountain a Ceelfiate of Camara ulbinsum far Wotkcr'sCompcm
,u provided for by Section 3700 of the Labor Code,for tte part....of the
for which this permit is issued.
nave and will maintain Watrr's Compensation Imuance,u teyuirN by Sectors
the(abm Code,for the perfamance of the work fa which this permit is issued.mkcrsCo pen ado,In ince cerrieai6A;Kcynumbcrrw.Poliry No.:_�E !r
CERTIF A E OF E f PnON FROM WORKERS'
COMPENSATION INSURANCE
(Thleuclion need not bu completed irthe permit Isforone hundred dollars($1(D7
or car.)
I achy that in the performance of the work for which this permit u issued.I shall not
employ any parson in my mourner an As to b«omc subjett to the Wohen'CompcmNon
Laws of California Dam
Applicant
NOTICE TO APPLICANT:IL after making this Certificate of Exemption,you should
n«ane subject to Ne Workers Compema.lon provisions of the labor Code,you must
0 forthwith comply with such provisions or this permit shall be deemed rooked.
'Z'-' CONSTRUCTION LENDING AGENCY
[�52 Thereby affirm that Nero is a construction lending agency for the performance of
p$r7 the work fur which this permit is issued(Sec.3037.Civ.C.)
QLenders Name
z Lenders Address
V Q 1 certify that I have rad this application and sate then the move information is
t'+ copeck 1 agree to comply with all city and county ordinances and sate laws relating to
OU building construction.and hereby.Inonse Rpre.natiMa Of this City m Cnmf Upon lW
r W above-mendonW property for inspection purposes.
gL (Wo)agree to save,indemnify sad yttp harmless the City of Cupertino agtasn
wF„fq liabilitlajudgmenu.cosa and expenses which may in any way accrue againv.id City
V Z in consequence of the granting of this permit.
" APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT Issued by: to
SOUR,E REGULATIGNS. I
ri"" " Z6 Z- Re-roofs
SLriare plmant7CmmMwu Dao
HAZARDOUS MATERIALS DISCLOSURE Type of Roof
Will the applicant or future building Occupant atom orhandle husrduus material
LIdefined by the Cupertino Municipal Code.Chapter 9.13,and the Health and Safety
7M!"Het?
e,Scction25532(a)? All roofs shall be inspected prior to any roofing material being installed.
❑ya
Will da applicant or future Wilding occupant use equipment or devices which If a roof is installed without first obtaining an inspection,I agree to remove
hanNous air co,taminams u defined by Ina Bay Area Air Quality Management all new materials for inspection.
❑Ye. l
1 have read the herardaus materials mquimmena under Chapter 6.95 of the Califor-
cxlthlkSafet Code,sections 75515,25533 and 25534.1 undersand Nm if the Wilding
not cunent]K"w a angina Net it is my ms onsihil'yn0 noul'y trc atopen.of N
ircmenist (inn mustW napdurmissuena cnlficateorOccup.ry. Signa a fApplica t Date
er or.umorid a actsate All roof coverings to be Class "B"or better