03120108CITY OF CUPERTINO
�COIVTRA.CTQR I1Yk'ORMAT
BUILDING DIVISION PERMIT
BUILDING ADDRESS:
'MORGADO-4 CONST.
PERMIT NO. 03120108
OWNER'S NAME:
PERMIT ISSUE DATE
E:
(408)275-0499
SANITARY NO. CONTROL NO.
ARCHITECTIENGINEER:
BUILDING PERMIT INFO
BLDG ELECr PLUMB MECH
0 0 o
LICENSED CONTRACTOR'S DECLARATION
Job Description
1 hereby affirm that l am licensed under provisions of Chapter Y (commencing
P
Bi rid a
with Section ]0(X) ofD" n3of NC Husinca end Pmfcasions Cndc antl H�yy�l';�B�a
inthof eandefrcct ds ,S(�.S'Jd S
LIeNs¢6 Class LM. Is
REISION--IN HOUSE USE ONLY
Da Contractor
NO NEW PERMIT ISSUED/ORIG.#03010158
unders dmypl RCHITE,�BE%pR�TodN
I�j�g,
STRUCT DET. FOR RETAINING WALL
-'
Licim dProfabom -
OWNER -BUILDER' RATION
I hcrchy affirm that I am exempt fru a Contractor's License Law for the
following reason, (Section 703 1.5, Business and Professions Code: Any city or county
Which requires a pctmit to construct, alter, improve, demolish, or repair any structure
-
prior us its issuance, also retinues the applicant for such permit to rile a signed statement
that he is licensed pursuant to the provisions of Be Contractor's License Law (Chapter 9
Sq. Ft. Floor Area
Valuation
(commencing with Section 7") of Division 3 of the Business and Professions Code) or
dust he is exempt Ceref cad and the basis for Be alleged mum, m. Any violation of],
Q %
Section 7031.5 by any applicant for a permit subjects due applicant to a civil penalty of
APN Number
OccupancyT e
not mom than fire hundred delta. ($500).
YP
❑ 1, ss owner of due progeny, or my employees with wags u their sole compensation,
will do the work, and the structure is not intended or offered for sale (Sec. 7044, Business
and Professions Code: The Contractor's License Law does not apply to an owner or
Required Inspections
property who builds or improves thereon, and who dressuch work himaelf or through his
own cmployces, provided that such improvements are not intended or offered for sale, If,
however, the building or improvement Is sold within one year or completion, the owner -
builder will have due burden of proving that he did not build or Improve for purpose of
ind
/`
1, az owner of property, am exclusivelynd contracting with licensed convectors i.
[]1.
❑
construct project
ees not(Sec.7044,wnerorand Professions Cuda:) Tina Convector's
O n '
Law
echo law dos not apply to an owner of property who or improves Corton, end
and
V
who ence Lacts for such projects with a contracmr(s) licensed pursuant to me Contnetoh
sed p
Lic
❑Ion exempt under Site ,B&PCfar this rcazon
V "'
Owner Date
WORKER'S COMPENSATION DECLARATION
I hereby alEmO under Penally of perjury one of the following declarations:
have and will maintain a Cenificatc of Consent to selbinsure for Workers Compnts
ashen, as provided for by Section 3700 of the labor Code, for Ce perfornm nro of me
work for which this permit is issued.
-
❑ (have and will maintain Work' a Com sstion Inaumnce, az rcyuirod by Section
3700 of me labor Cook c Ce performs of dm work for which this permit is issued.
.,
My ti nsurans 'cyan Policynum art:
Icy
ERTIFl OF EX PnON FROM WORKERS'
MPENSATION INSURANCE
(Thu section need not he completed if the permit is faronc hundred dnllarai nl(10)
or Icsk)
.
1 cenify that in the Performance of the work for which this Permit is issued. I shell not
employ any person in any manner so az to become subject to the WorkeW Compensation
Laws of California. Data
Applicant
'
NOTICE TO APPLICANT: If, after making this Cenificane of Exemption, you should
become subject to the Worker's Compensation pmvisions of Ce Labor Code, you must
forthwith comply with such provisions or this Permit shall he deemed revoked.
CONSTRUCTION LENDING AGENCY
I hereby affirm that there is a construction lending agency for the Performance of
due work fur which this permit is issued (Sec. N097, ON. C.)
Linder', Name
Lender's Address
1 cenify that 1 have read this application and sum that Be above Information is
corm. l agree to comply with all city and county ordinances and cute laws relating to
Wilding construction, and hereby authorim representatives of this city to onto! upon the
abovmmemioned properly for inspection
(We) agree m save, indcmni fy and keep hornless the City of Cupertino against'
which ms.
''mcna. roam and expenses which may in any way accrue against City
IiebiDLICA
o
A ufduERrenuNRAND WIL MPLY WITH ALL N POINT
Issued by: DateS
ATI S.
Re -roofs
Type of Roof
a r ApplicanUCom r Data
HA US MATERIALS DISCLOSURE
Will the applicant ur future building occupant store or handle hazardous material
as defined by the Cupertino Municipal Code. Chapter 9.12, and he Health and Safety
Code. Section 25532(a)?
L' ❑Yea Nu
All roofs shall be inspected prior to any roofing material being installed.
If a roof is installed without first obtaining an inspection, I agree to remove
Will me applicant or !owns building occupant s equipment or aevms which
hauardos air Cio uminana as defined by the Bay Amu Air Quality Management
all new materials for
do'?
0Yes No
I have mad the hanrCws materials reyuiremcms under Chapter 6.95 of the Cslifn,.
ria Heald A Safety Code, Secuoty 25505, 25533 end 25534.1 undersand thatif the building
Jas tcu ntly h w a at itis my res ihility to nodi' mcuPont of the
rcyu mments Ix nor .azoanc P to Ce naPfr. (
Signature of Applicant Date
_
loam
All roof coverings to be Class "B" or better
caner nr a t rix d agent