02110078 CidTMF CUPERTINO "` "<
(c&QNGN DOWN RYERMIT CONTRACTOR INFORMATION:
BUy;gl(J('MEJOHN M PERMIT NA.2110078
BUM
NAM AND SHAR ll
OWNER'S NAME: r SUITE-•' 200 APFLICA7J0�4712/2002
1 A,oZONE: SANITARYllN.LO.. / CONTROL NO.
rk -b Ls�, cum , 2d
ARCIHTECT/ENGINEH . BUILDING PERMIT INFO
BLDG ELECT PLUMB MECII
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LICENSED CONTRACTOR'Snsedunderp DECLARATION WATER RR'ARp S l�tljllL
o Z F 1 hereby affirm that 1 am licensed unlet provisions ofChapterCopmr 9(commencing HEATER c tat l fl'f�j f j'
<8 with Scaian 70fN1)of Division Sof Ne Businexs anti Professions Cole.anti myliccau is
in
DLieDLiaccfmcunuId understacnfdr m
y plane hull's he CusucnJuesFIaA L C
Lic.X 37
COO
ARA
FEB Q 4 2003
LLj Professional
DECLARATION
o
z <y 1 herchy affirm that I am exempt from the Contractors License law for the BUILDING T
T E:00 following much.(.Section 7031.5.Business and Pnlfessions Code:Any city or county �Q0
$ which requires a permit to consumer,alter.improve,demolish,or repair any structure
Z>• Poor m its issuance,also recons the applicant for such Permit to a signed statement
�� that he is licensed Pursuanuo the provisions of the Cmnracuv's License Law(Chapter 9 q. or ea Valuation
(commencing with Section 7000)of Division 3 of the Business and Professions Coda)ry
y that he is exempt therefrom and Ne basis for the alleged exemption.Any violation of
Section 7031.5 by any applicant fora permit subjects the applicant to acivil Penalty of 5 0 6 AP Y Occupancy Type
not more than five hundred dollen(SSm). J ES T
❑ h as owner of the property,or my employees with wages as matt sale compensation, 5 0 7
will do Use work,and the structure is not intended oroffered formic(See.704,Business
and Professions Code:The Contractors License law dues nut apply m w
an owner of Required nspections
property who builds or improves thereon,and who doer such work hinnu for through his
nwn employees,provided that such improvements am sun im ended oroffi red formic.If.
however,the building or improvement is sold within One year of completion,the owner
builder will have the burden of proving Nat he did not Wild or improve for purpose of
sale.).
0 1,as owner of the property,am exclusively contracting with licensed contractors to
consumer the project(Sec.7044.Business and Profusions COdC:)The Caatraelorl Li.
cense law does not apply to an owner of property who Wilds or improve thneon,and
who contracts for such projects with a cunuactor(p licensed pursuant to the Contractor's
License La-
0
a W.
1 am exempt under Sec. B&P C Int this Mason
Owner Dam
WOR KCR'S COMPENSATION DECLARATION
1 hereby affirm under Penalty of perjury one of the following declarations:
0 1 have and will maintain a Certificate of Consent to self-insure for WOrker'sCompen-
mtion,as provided for by second 37W of the labor Code,for the Performance of the
work for which this permit is issued.
I have and will maintain Worker's Compensation Insurance,as required by Section
7 I of the tabor Code,for the Performance of rbc work for which this permit is issued.
My Wnrker'sC�p/ye/fryksatii�JLlnsurety�e canicrand Policy nu herart'Iy
Carrier: P�. %"r^ KJ Policy No.: �r ZJ-0
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(This section need not W completed if IW fermit is forme hundred dollars(511X0
less.)
1 certify that in the performance of the work for which this Permit is issued,I shall not
employ any person in any manner so as to become subjut to the Workers'Compensation
Laws of California.Dare
Applicant
NOTICE TO APPLICANT:If,after making this Certificate of Exemption,you should
become subject to the Worker's Compensation provisions Of the Labor Calc,you must
OO forthwith comply with such provisions or this perm it shall he deemed revoked.
z CONSTRUCTION LENDING AG ENCY
Ihomhy ani rte Nat me to is a consuunlon lentil ng agency for the performance of
the work for which this permit is issued(See.30)7,Ci,C.)
W� Q Lender's Name
z Lender's Add..
J O 1 certify mat 1 have read this application and stme that the above information is
L,i h noted.1 agree to comply with all city and county ordinances and stem laws minting to
0U building construction.and hereby authorim representatives of suis city to enter Upon[he
>i W above-rdemitowd property for inspcchnn purposes.
(We)agree In save,indemnify and keep harmless the City of Cupenina Up tell
tih liabilities,judgments,costs and expenses which may in any way accrue against sail City / r
U 7 in consequence of the granting of this Permit, l/ /
a APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL ONPOINT Issued by: Date
SOURCE REGULATIONS.
n � °Z Re-roofs
Signature of Applicam/Commnor Date
HAZARDOUS MA RIALS DISCLOSURE Type of Roof
Will the applicant or future building o,XUPant atom(iT handle havallous material
as de0ned by rhe Cupertino Municipal Code,Chapter 9.12,and the Health and Safety
Code,Section 29532(x)'! �N� All roofs shall be inspected prior to any roofing material being installed.
DWI
Will Ota applicant or future building occupant use equipment or devices which If a roof is installed without first obtaining an inspection, I agree to remove
,mit h,mJous ail Contaminants ax defrod by the Bay Area Air Quality Management all new materials for inspection.
District?
❑Yes aAFr•
1 have mad the hazardous materials requirements under Chapter 6.93 of the Cithfot-
nie Ilcalm&Safety Code,Sections 25515,25533 and 255341 understand that if the building
does not Currently have a tenant,mat it is my mop nxi hility to mildly IW Occupant of the
rcquiremc hien mm prior w' uanecmfacenificaem Panc.o2 Signature of Applicant Date
Owner or a.morircUa m / ate All roof coverings to be Class "B"or better