04040186 CITY OF CUPERTINO ' ' "7777777777777777777s,k�y ^ n }s "
BUILDING DIVISION PERMIT 'CQNTRAMR I11A'� MNT}ION r,
BUILDING ADDRESS: WK CONSTRUCTION PERMIfy1 .040186
1
OWNER'S NAME: PERMIT ISSUE GATE '
04/28/2004
HONE: SANITARY NO. CONTROL NO.
408 615-1508
ARCHITECT/ENGINEER: BUILDING PERMfT INFO
BLDG ELECT PLUMB MECH
y00 LICENSED CONTRACTOR'S DECLARATION Job Description
1 he chy affirm that l am licensed under provisions ofC oder Y(commencing p
Z with Sectio IXk1)mf Divixion3of the Bulinus end Professinm Codc end mylic,n.,a '
<< inruum
ad erre oL EVISION--TRUSS
i LI� License Lie.a
a Dart cummcas 110 NEW PERMIT ISSUED/ORIG. #03080015
ARCHITECTS DECLARATION
�i
,, i.dcxaeSy.plans shall he used asp 'c rccards
OyU
G LL ntfcldl
g NER BUILDER DECLARATION
02 1 hereby affirm un 1 1. exempt from the Contractor's License Lew for the
OO following uiresa ermitt 7onstr Business and Pe.dermis Code:Any city structure s�m� which reyuurcsapermit recorse,ahem improve,h formitume a sig anysaucWre
FZa that beor irecensed c,also
uantto the the applicant
s(if for sucContrarmuuoiense La (Chapter
Chart cm
that pursuant 7 the of Division
the the Business
License law(C Code)or Sq.Ft.Floor Area Valuy ilzlm7
�}�G JOLhe is exempwith teefrom and of basiionr of sheeged casand Profcsyvi Ction of
that he is exempt therefrom and dw basis for the alleged exemption.Any violation of
Section 7831.5 by any eppliant for apermitsuhjccta the applicant to a civil penalty of APN Number Occupancy Type
not lame than five hundred dollars(SSW). 37513028 . 00
p y YP
❑1,u owner of the property,or my employees with wages as their sole compensation,
will do the work,and the structure is not intended or offered for sale(Sec.7044,Business
and Professtons Code:The Contractor's License Law does not apply m'an owner of Required Inspections
property who builds orimproves thereon,and who does such workhimselfmrthrough his
own employees,provided that such iespmvemenu us not intended oroRered for sale.If.
however.he building or improvement is sold within ane yearof completion.be owner-
builder will have the burden of paving that he did not build or improve for purpose of
sale I
❑1,as owner of the property,am exclusively contracting with licensed contnedors to \
consw4,cl the project Basincu end Professions Code:)The Cimar hrh Li
cense law docs not apply to an owner of property who builds or improvrs Ihemon.and,
who contracts for such projects with aonn"ctor(s)licensed pursuant Be the Convatots
License Law.
❑lamexemptureau See. ,Bk PCfmdUnaan -
13�700ofdw
wner Data
WORKER'S COMPENSATION DECLARATION
1 hereby efrom under penally of perjury one of the following declarations:
1 have and will maintain a Certificate of Consent to self insure for Worker's ComPen-
ion,u provided for by Section 37W of me Labor Code.for the performance of the
rk for which thus permit is issued. ..... .+ c
I have and will maintain Worker's Compensation Insurance,as required by Section
laborCodc,fortact performanceofthe work forwhich Niscrni tis issued.
yWorker's Cmtpentiondn Imearoee artier and Polic num to--
r. Policy N 0�6
CERTIFICATECEIk MONFROM WORKERS'
COMPEN gNSURANCE
(This well=freed not he completed If the permit is formic hundred dollars(SIM)
lir less.)
I certify But in the pourormanec of the work for which this Permit is issued.l shall not
employ any person in any mawerkn,ulnhocomc subject m the workers Compensation
Laws of California.Dau 4yl MI
Applicant
NOTICE TO APPLICANT:IL after making this Cenificau of Exemption,you should
become subject to the Worker's Compensation provisions of in.lahnr Code,you must
.J Z forthwith comply with such provisions or this Permit shall be deemed revoked. -
Z OCONSTRUCTION LENDING AGENCY
V)
I for
rwhichum that thereiw construction lending agency for the Performance of
the Lewmkforwhich this permit 1.issued(Sec.]097,Civ.CJ
Q Lcndcr's Namc
]z LendeYS Address
U 0 1 certify rho I have read this application and sate that the or.tnfomiuiun is
ly P correct.1 allow to comply with all city and County ordinances and stale laws relating to
0 U building cmnswcdton,and hereby audhorim representatives of his eity to enter upon the
W above-mentioned pmperty,for inspection purposes.
y (We-)agree to save,indemnify and keep harmless the City of Cupertino against
U1 liabilities,Judgments,costs and expenses which may in any way accrue against said City
Uz in consequence of the grans ng of this permit.
r-s APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT Issued by: Date
SOURCE REGU ATIONS. ' /
ef y�-�" �`�� `1� &l� Re-roofs
Signa heof AppECIOUContrazmr V Data
HAZARDOUS MATERIALS ISC URE Type of Roof
Will the applicant or future building occupant handle hazardous material
u defined by the Cuperttmo Municipal Code.Chapter 9.12,and the Health and Safety
cmde,se<limnzss3z(an
Yea
No
All roofs shall be inspected prior to any roofing material being installed,
❑ R
Will the applicant or future building occupant use equipment or devices which If a roof is installed without first Obtaining an inspection,I agree to remove
mut hazardous air contaminants as deleted by the Bay Area Aur Quality Management all new materials for inspection.
istflet, p -
❑Ycs kV1Nu
I have mad the bastard
ous materials requirements under Chapter 6.95 of the Califor.
nia Health&SafetyCodc,Smumu255)5,25533and25534,Iunt m=dNalifthe building
docs not curtently have a nonan,that it is my responsibility as nouly be occurred of the
reyuircmcnm ichmybcmelpmOrtonswaccmrac, III f0capanfLy Signature of Applicant _ 'Date _
CUsiolisafr authorized agent (Date All roof coverings to be Class"B"or better