01020060 CITUf OF CUPv,R�NNO CONTRACTOR INFORMATION:
PERMIT
ISUILDING ADDRESfr. PERMn'NO.
LEBANBN DR . — AND H LLA 111101020060
WNIiR'S NAM: APPLICATION SUB DATE
02/14/2001.
IIONG: AND SANITARY NO. CONTROL NO.
w O O=hemby.iffion
BUII. NG PERMIT INFO
8�R Fpy BLDG EV PLUMB MECH
y 4 E CI L7
EEEED CONTRACTOR'S DECLARATION
z 5 N'' ttttt heensm ander to nrcrin tat 9 fcommenein Job Description
proms of p b
�:� with 5catinn]WB)of Di'M...itnfthe Business and l'nde>siuns Code,and mylicense s
SMS LimmeClnssand errec LichCONVERSION FROM O. H Ta. O UNDERGROUND
O vi Ume Conwcmr
ARCHITECT'S DECLARATION
(:LL 0� 1 understand my plans shall be used as public records '7�'C� / — � 131W'u3 r /✓(J// f7///'//
as
i p O Licensed Ptofessi...1
o OWNEILIIUILDER DECLARATION
I hereby affirm mat 1 am exempt from the Cmnmetnr's License Law for the
rnllowing rens o i (Section 70315,11 inCs wad 11 5..lnns Cnde:Any city or ant my .
O which roquirm a pentat m construct.ulcer,improve,demolish,nr repair my wetter.
i Priorto its issuance,almreyuirt.s theapplicent forameh(wrmiva lileasigned statement
n. that he is licensed pursuant to the previsions of the Contractor's License Law(Chapter 9 Sq. Ft. Floor Area Valuation
(commencing with Section 7g31 of Division 3 of the Business and Professions Cafe)
or that he is exempt therefrom and the basis for the allege)exemption.Any violation
of Senion]1131.5 by on pplicam for a Ir¢rtn.1 objects the applicant to a civil penalty
of nn{\m re beta fiweIt Jrcrk\dorr (��ssdo).�� APN Number Occupancy Type
4II,uso� tthc pr"� or my cops their stile compenwrnn,
II do the work,and the structure N not intended or offered for sure(Sec.7114.
Business and Pndassinns Coda The Contractor's License Law does not apply in an Required Inspections
ow or pro,ca,Who hulld,or improors hereon,and who docs such work himselr '
oor through his own empl(yo s'.provided that such improvements are not intended or
ffered for sale.IL however,the bulling or improycmem is sold within one year car 304 — ROUGH ELECTRICAL
completion,the owner-Wilder will have the burden of pawing that he did not lamidor 501 — FINAL ELECTRICAL ENERGY
improve for purrow of cols.).
El 1.as owner of the propery,am exclusively contracting with licensed canonical to 505 — FINAL ELECTRICAL
consumer the pmjmt(Sm.7(034,Business and Pn,feaeinm Ctde:l The Commnnr'a -
License law does not apply to an owner of progeny who build,car improves thereon,
and who coronets Iter such projects with a contracuma)'licensdl pursuant to the
Commnors Llceree I.aw.
°l uta exempt uncrr _1,II&P C for this rens on
)wnerl�Date Z 1 /d/.
•WORKER'S COMPENSATIO DECI ACTION
I hereby affirm under penalty of perjury one of the fallowing declarations:
❑ 1 have and will ace mm.it Certificate of Consent to selbinore for Worker's
Compensation, an provide[ for by'Senion 3713 of the labor Cade, for the EXPIRED
performance of the work for which this permit is issued.
01 havenod will m tintnin Worker's Compensation houncov.as rco doral by Section
3703 of the labor Cnde,for the performance of the work IN which this penuit Is
sued.My Worker's Compensation Insurance carrier and Polley rourkr are:
Carrier. Policy No.:
CERTIFICAI'1(IN OP E%EMP130N FROM WORKERS'
COMPENSATION INSURANCE
(This section need nm be cottlpkmd if the permit is for one hundred dollars
fg l(3)nr lest.)
1 certify that in the perl'nrn..see of the work In,which this permit Is Issued,I
shall not employ any person in any mmoner ,,as to hccotnc subject m the Workers'
Co r,mantion laws of California.Dare
Applicant
NOTICE TO APPLICANT:If,otter tanking this Ceniticate of liacmpoors Yml should
Q Oresume,subject all the Worker.Conpensmion pro hions of the Labor Cade,you most
forthwith comply with such gnwisions or this permit shall h drama l reaction.
z �
F CONS here is.mo LENDING leading
apoY
aiIhercor whitm this thnrcisaconed(Sec. lendings.C.) for the perfnrmoncc
W of the work for which this permit is issued(Sec.3fyJ7.Civ.CJ
L,ul Nunn
z header's Address
t, C 1 certify that I have read this application unJ.late trim the above information ix
Pk F.t correct.1 agree to comply with all city and county ordinances and scale laws relating
V to building construction,and hereby carbonize representatives ofthis city to enter upon
the aMve-mentioned propery for inspection purpnsex.
1y Dox)agree to save.indemnify and keep harmless the City of Cupertino against
V] liabilities,judgmcnta,costs and expenses which inay in any way accrue against said
L) 7-. City in consequence of the granting of this permit.
.S'II,UL�ICEA,RI'.C1USn LAI 503 Iy'AND WILL OMPLY WITH LLNO"�POINT Issued by: Date Z ( ^�/
�/� � ���4 /OI
v�snafareofApinennn omrtt,nratm Re-roofs
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant to Imam Ntilding ouvpant smrc car hnnJk haaallous material Type of Roof
as drained by the Caperton Municipal Code.Chapter 9.12,and the Health and Sufey
Cuda Section 255320)?
°Yes 0 N All roofs shall be inspected prior to any roofing material being installed.
Will the applic rt ar future building occupant use citural tit or devices which If a roof is installed without first obtaining an inspection, I agree to remove
nit hazandous air contaminants as defined by the Bay Area Air Quality Management
slriee all new materials for inspection. Applicant understands and will comply with
❑Yes °No all non-point source regulations.
tIf
.
I have read the Wouraus materials requirements under Chapter 6.95 of the
California Health&Safety Coale,Sections 25505,25533 and 25534.1 understand that
if the building does not cutrtmly have a tenant,that it is my responsibility to notify the
oecupmn of the ray v which must Itacred,prior,,i...name of a Camificme or
aw,e1lo. 2 I11 4 ale
Signature of Applicant Date
Owner oaatnari,sed ittd sen, Dale roof coverings to be Class"R" or better
OFFICE
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