04050011 CITY OF CUPERTINO 777,777,77 7'7
77,777' 717 p'}s r rg�} 'e�Tar
BUILDING DIVISION PERMIT �4<�a 4 WR INF0F�lY AT-101`I
BUILDING ADDRESS: PERMIT"04-050011
O-4050011
ER-S NAME: PERMIT ISSUE DATE
T. RZF.T.0mr
NE: SANITARY 2 CONTROL NO.
ARCIAMCIfB3NGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
0 0 0 0
u0o LICENSED CONTRACTOR'S DECLARATION
I hereby afford that I am 1lcensed under provisions of Chapter 9(commencing .lob Description
Z with�s 0 7") fl) ision3ofdtc Bminussend Pmfcuionsde mdmylicensels
^may in(ulTfalgband e lC 3 - g% p COLAR PANEL PHOTOVOLTAIC
n LiccnaaCTess Lic,
Dam cametor ONTRACTOR: SERVCO CONSTRUCTION
-ARCHlTE=S ON
1 understand my plana shall be used c-cords
3 is
LLO�j Licensed Professional
OWNER-BUILDER DECLARATION
f 1 hereby affrm out I am exempt fru.tx Commutators Licenac Lew far the
Q O following reason.(Section 7031.5,Business and Profusions Code:Any city or county
s�$ which requires a permit to construct,almr.omprasw,demolish,or repair my st.w.
ad priorto its I.......1.metal.the applisem for such persaiuu file asilponimmment
<
thin heislicensed pumu
uenntxpmvisinnsn(theConmtrmhLittnselaw(Chepmr9 Sq.Ft. Floor Area Valup,E1(!1000
P (commencing with Section 7")of Division 3 of Ne Business and Professions Code)or h'
3$ Nat he is exempt therefrom and the basis for Ne alleged exemption.Any vloldaon of
Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of APN Number Occupancy Type
not more Nan five hundred dollars(SSW).
❑h as owner of the pmpeny,or my employees with wages as thein sole compensation, 34214033 . 00
wan do the wank eed theawcture is net intended mo@¢d faraale(See.7WA,Business Required Inspe
and Professions Code:The Comment's License Law Mica not apply to an owner of q P
property who build&or improves thereon,and who does much work himself or through his
own employees,provided that such impmwmenm are not intended-offered for We.If,
however,Ne building or improvement is sold within one year of completion.Ne ower
builder will have the burden of proving Nat heedid not Wild or improve for purpose ofumJ.
Q 1,as owner of the property,am exclusively contracting with Immusi d contractors in /
construct Ne project(See,7044.Business and Professions Cade:)The Contractor's U.
come law does not apply to an owner of property who Wilds or Improves themon,and
who contracts for such pmjem with a conuador(s)licensed pursuant to the Conv¢toh f j
License Law.
❑lamexemptunder Sec. ,B&PCforthiaremon
137Mr Data �< J
WORKER'S COMPENSATION DECLARATION aJC
1 hereby affirm under penalty of perjury one of Ne fallowing decimations:
ave and will maintain a CcrdRam of Consent insel6imum for Worker'sCompcm
,as provided far by Seermn 3700 of die tabor Cad.,for the performence of the
for which this permit is issued.
ave and will maintain Worker's Compensation Inaurm¢,as required by Section
of the labor Code,for tx performance of Ne work for which this Permit is issued.
orker's Campensedon loses ce carticnnu Policy py,m
V—
-:
' Ei Foff s(i
CERTIFICATE OF MMPI'10NN''FFrtrtOM WORKERS'
COMPENSATION INSURANCE
(Tbls section need nota complcmd if the parrot is forms hund-d dnllam(5100)
or Ices.)
I terrify Nat in the perfommnee of Ne work for which this permit is issued,1 shall not
employ any Person in my mannerso as In,become subject to the Workers'Compensation
Laws of California.Dam
Applicant
NOTICE TO APPLICANT:If.after making this Certificate of Exemption,you should
become subject to the Worker's Compensation provisions of Ne Labor Code,you must
O foMwith comply with men provisions or this permit shall be deemed revoked.
,zCONSTRUCTION LENDING AGENCY
[—i y. I hereby affirm that them is a construction lending agency for Ne performance of
ai> the work for which this permit is issued(Sec.3097,Co.C.)
W Q [..&,'a Namc
z Lender's Address
U 0 1 certify that I have mad this application and stem that Ne show information is
D.(~ correct.1 agree to comply with all city and county on insnces and seem laws relating in
O U building construction,and hereby malodm miumsenutives of this city to toter upon the
W .1mm-n mooned property for hopeeMM purposes
LL (We)agree to nave,indemnify and keep harmless the City of Cupertino against
o-y y liabilities,judgm.nm,cuss and expenses which may in any way same against said City.
C.)Z in consequence of the granting of this permit
.. APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT Issued by: Date
SOURCE ULATIONS. Q r 0 A tlN
D '1 Re-roofs
rgnuu-ofApplicaR vector ate
Lf HA BOGUS MATERIALS DISCLOSU Type of Roof
Will the applicam or forum building occupant seem or handle hmardous material
defined by Ne Cuperin,,M$,I Code,Chapmr 9.12,and the Health and Safety
a'section 25531(s)7 All roofs shall be inspected nor to an roofing material being❑Yea No P P � Y g g installed.
11 Will the applicant or future building aceupant use equipment or devices which If a roof is installed without first obtaining an inspection,I agree to remove
Fin hey.micus air contaminants as defined by Me Bay Area Air Quality Management all new materials for inspection.
District?
❑Yet Nu
1 have mad Ne Woodcut arsenals requirements under Chapter 6.95 of the Califa>
ria Health&SafelyCoce,Sections 15505,25533 am115534.1 sanders d thmifthe huoldong
does not cumnily haw a tenant than it is my responsibility to noril'y emunam of the
mqui:;=rust x met prior to issuance of a Ccrtifcase of Occ N Signature of Applicant Date
own oraumo y<dag.nt 0 am All roof coverings to be Class "B" or better