04030012 CITY OF CUPERTINO `4
BUILDING DIVISION PERMIT 0N,TRACTOR I1V,0kW 0N.
BUILDING ADDRESS: KOOL METAL PERMITNo04030012
al 71 T.R.RANON nR
-
RS NAME: PBRMD ISSUE DATE
AURELIA CO
: SANITARY NO. CONTROL NO.
(408) 245-6597
ARCHITECTIENGINEER: BUILDING PERMIT INFO
BLDGO ELECT l� PLUMB MECH
O l�
Loo LICENSED CONTRACTOR'S DECLARATION JbDescription
I hereby arcm Wbt 1 am liaad o
nunder provisions of Chapter 9(commencing
a� with Section 7000)of Division 3 of ftBusinea and Profession ¢u
Cade.and my license
I.ran rarer and crcece AWNING
j n z License Class Uc.g
n Dam Contract(
ARCHITECTS DECLARATION
>: 1 tual stand my plans shell M used as public record;
30� Licensed Pmfcsew al
OWNER-BUILDER DECLARATION
iV I Mreby mErm that I am exempt from Ibe Contractors License Law for sM
O o following reason.(Section 7031.5.Business and Pro(easiom Cade:Any city or county
$ which requires a permit to construct,alter.Improve,demolish.or miser any nrmmre
FZSn prior m its issuance.Alto requires the applicant for such Permit to nit a signed statement
< that he is licensed pursuant to the previsions of the Contractor'License Law(Chapter 9 Sq. Ft. Floor Area Valuation
$ (commencing with Section 7000)of Division 3 of the Bud nes end Pollinators Calls)or
.. that M is mumps Nemfmm and the basis for she alleged eaemptlon.Any violation of
Section 7031.5 by any Applinnt for a Permit subjects the applient ke a civil penalty of 3 4k?N4a hMer0 0 Occupancy Type
nos mare Nan Biro hundred dollars($500).
❑Luowmsa(Indp ft struc m is intended
whinwageuth.(Sec.compmwtim,
will do thework.ande.Thc oldisterset's Lndedarowredfor We(Sec.]0as, oncrof
and ertym orts Code:The Ces,der ors Licence Law dors not apply lf rt owner of Required Inspections
propempla b,pmidedildamr p.vcuhemon,enmenU msswh work bimatelfor femdNmuge M; ,..5
own employee,providetl thatwch improwmenu are w year ofc mortem,Tressle.ir. Ijl
however,Ne Wilding.r Improvement is sold within ow year of mmpletian,Ne awmr
builder will haw burden poor at M did no Wild or Improve:for purpose of
t etdfiv � —�vatw
e ro m ly ren ng thl' ren nm
cmnhnt pmjee(Sec.701x,Business and Profession,Code:)The Comracmrs U.
cense Law does nal apply to an Mummer property wM Wilds err improws thereon,and. r
who contracts for such projects with a emm ctor(U licensed pursuant to the Committers
License Law. -
L]lamezemps/uq/der Seer//���j � B&PC fors th```ispppresssa��'so```n -
ru�I,.f,a//i1/YLi. /�O..A/.11 Dam
(..� ORKERSCOM ATION KATION
I hmeby.111.under purdy of perjury ore of the following declatathow -
❑1 brae and will maintain n a Cat40ete of Cement to self-haunt for Workers Compen.
moon,a providbd for by Sermon 7700 of the Labor Cotle,(m the Performance of the
work for which this Permit Is issued.
❑I haw and will maintain Workers Compensation loran¢,as required by Section
3700 of the labor Code.for the performance of da work for which this permit is lssmd. '
My Workers Compensation Insurance carrier and Polity number art:
Carrier. Policy No.:
CERTIFICATE OF EXEMFTION FROM WORKERS'
COMPENSATION INSURANCE
(This sentient need nwitecompleted Ifthe permit is froom hundred dont ser(Sim)
or less.)
I unify that In the perfmmanm of the work fro which Nis Permit u issued.I tall not
employ any person in any mmrcr se e in become abject to the Werken'Compensation
Laws of California.Dam
Applicant
IC
NOTE TO APPLICANT:If.after making this Ccnific on of Eumpslen,you shmld
become Subject m the Workers Compensation provisions of the Labor Code,you must
.J O forthwith comply with such provision m his permiuhail W deemed rewkcd.
r y CONSTRUCTION LENDING AGENCY r
[—� Ibereby drum that there its construction lending agency for the Performance of
l>: the work for which this Permit u Wood(Sec.3097,Co.C.)
aQ Lenders Name
D z Lender's Address
UQ I certify shut 1 ban mad this application and sum Nn the above InformNun is
11, r' correct.1 agree to comply with all city and county ordinances and sum laws minting m
DU building construction,and hereby authorize representatives of this city m enter upon the
W abovomcnhned Property for iaspecdon pugnses
gL (We)
agree to an.indemnify and keep armless lM City of Cupertino against
rq Ilabilitiesjudgments.costa and eaporms which may in my say scam almost said City
U z in emosquence or the grating of this permit.
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT Issued by:qJ4-Q�&j FJ�V Date
SOUR
REGULATIONS.
' !6 . 3' Z'01A Re-roofs
umaf p on r Dau
HAZARDOUS MATERIALS DISCLOSURE Type Of Roof
Will
�,� z _. �y
W01 the applicant m future Wilding occupant mom or handle a mous materiel L/ III
definmi by tie Cupertino Municipal Code.Chapter 9.12,and the Health and Safety
trema 25512(')' t� All roofs shall be inspected prior to any roofing material being installed.
Will theapplicant or future building occupant use equipment or devices which If a roof is installed without first obtaining an inspection,I agree to remove
ami,hazardous air contaminants u will by the Bay Area Air Quality Management all new materials for inspection.
DietrinT
❑Ye gTlu
I have read the aurdms materials requirements underClupmr 6.95 of the Glifor.
M.He tr&SdetyCodc,Sasimu 25505.25533 and 25534.1 understood men If me Wilding
does not currently haw A tenant that is u MY reponihility u mu ry tic occupant or use
rtyuimm whmnma Mmespriar ;FurteetearOccupanry. Signature of Applicant Date
lYw sae egY�n� Date All roof coverings to be Class"B"or better