03090055 CITY OF CUPERTINO
BUILDING DIVISION PERMIT �CONTRAC-TOR INFORMATION h
BUILDING ADDRESS: TARN' S CONSTRUCTION """03090055
OWNER'S NAME: PERMIT LSSUE DATE
E: SANITARY ONTROL NO.
ARCHITECT/ENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
0 t t� t�
LOo LICENSED CONTRACTOR'S DECLARATION
x a1 thereby affirm that I sm licensed under provisions of Chapter 9(commencing Job Description
with Section 7")of Division Sof NC Business and Professions Code.and my license is
in full forte and cffem
umoscClasa Lle.11 TI--ACUPUNCTURE CLINIC
��p Dow Conlncr
r mARCHITECTS DECLARATION
��LL$qq$ 1 utdcrssand my plans shall h u m
used public cortla
06
4o t' Liccnsed Professional
3 OWNER-BUILDER DECLARATION
1 berth,strum that I am eacmpt firm dm Contmaors Lima.Law for the
p o following mason.(Section 7031.5.Business and Professions Cade:Any city or county
which requires a Permit to construct,alter.improve,demolish,or repair any stmmte
c
y$y prior to its issuanm.also requires the applicant forsuch Permit to file a signed statement
�sZs<
that he u licensed Purroanuo the Prov(si9m of the COn=i S 1.i4rnsc Law(Chapmr 9 Sq.Ft. Floor Area Valuation
mFth (commencing with Section 7100)of Division 3 of the Business and Professiam Code)ar
i $ Out h u esempt thmfrom and th basis for One alleged exemption.Any violation 9f
ooh mom om D31.5 Our live hundreditdollus(M). subjects due applicatnmacivil penalty of APN Number Occupancy Type
0 L As owner of the property,or my employees with wages as Heir role compensation, -
will do las work,and the swmum is not intended reoffered for sale(Sm.7W,Business 32633
and Pmfessiom Code:The Conufmm's Limme Law does not apply in an owner of 0 0-Required Inspections
ownenywhobuiprovidmpovuchreon,anLwho dmnonchworkrnakid offerar through his
owneer.the uprovidedthatsuch impmsemenuare notimr.f women.for sale IL
however.thebuilding.,have
t improvement is sold within oro year of mmpine for the owner-
builder villi have th burden of proving Nat h did not Wild or improve for poryoa of
sole.).
tas owner of the property,am uduaivcly contracting with licensed con tmewas to
hrust the project(Sea 1044,Business and Profconom Code:)Th Conmcters Li.
came Law does not apply in in owner of progeny who builds or improves Neuron,and, \
who contracts for such projects with a contractor(s)licensed pursuant An Ute Conuaeteh
C]I IJW. /
❑lam teem Sm ,Bk PC for Nu rusan pp
OwneL Da
01
r� S COMPENSATION DECLA N
I hereby aRrm under penalty ofperjuryonnafthe' ing declarations: �e
Ihaveand will mainuina CeNfteamof Cream,self-insure for Workers Compen- 1 `�
action,u provided for by Section 3700 of the Labor Code,for thc Performance of the V
work for which this permit is is ad
❑1 have and will maintain Worker's Compensation Imorance,as required by Scwon
3700 of the labor Code,for Ne performance of the work for which this Permit is hutted.
My Worker's Compematian Insurance canis and Policy number art:
Cartier: Policy No.:
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(Thiusmtim need Mt he camvieud if the permit is for.hundred dollars(SIM)
or I..)
I certify that in Oc performance of the work for which this pemtit is issued,I shall not
employ any person in any mmnerm as to become subject o the Workxmi Compensation
Laws of California.Data
Applicant
NOTICE TO APPLICANT:If,after making this Certificate of Exemption,you should
become subject to the Workers Compensation provisions of the Lahr Code,you muss
0z forthwith comply with such provisions or this permit shall be dammed revoked.
z CONSTRUCTION LENDING AGENCY
[•+ I hem by affirm Nie Nem is a ed(See 0 lending agency for the perfarmenm of '
C the work for which this permit is issued(Sec.3091,Civ.C.)
Q lender's Name
ZL
.7 z lender'sAddmu
U C) 1 certify that I have read Nis application nod tam than one above information Is /
{L.Pcorms 1 agme incomply with all city and county on inames and sum laws minting to
(]U Wilding conviction.and hemby amhodm mpresentaivu of this city An enter upon Om
on
G above-mentioned 0,granting
for imPhis Pemitpwses. f
(We)agree to save,indemnify and keep hamdcss to City of Cupertino against
.Fi fA
liabilities,judgments,ensu And expenses which may in any way accme against said City
(„)z A PLICANT ofthgranting Sthis vermis.
APPLICANT UNDERSTANDS AND ILL COMPLY WITH ALL NON-POINT Issued by:S44 Dat
SOURCE REG ONS.
^^ 02
Re Re-roofs
St atureoftc
A anUConbacmr
HAZARDOUS MATERIALS DISCLOSURE Type of Roof
Will the applicant or future building occupant store ar handle havardous material
As&Fred by the Cupertino Municipal Code.Chapter 9.12,and the Health and Safety
ewe, El Y.sss3z(a)1 L4 All roofs shall be inspected prior to any roofing material being installed.
Will due applicant of future Wilding occupant use equipment or devices which If a roof is installed without first obtaining an inspection,I agree to remove
Distria"ard"m air contaminants as defined by On,Bay Area Air Quality Management all new materials for inspection.
by.. WIN.
1 have read the hasrdousmauriaismqui emenu undcrCupar 6.95 ofthc Califon
niceHulth&SafctyCode.Sa4om25505.25533 atW25534.iundersund thuifNc Wilding
docs tat carne aw a rename that it is my responihility ke ratify the occupant of the
re,ancoun hich unhmet plotOnmncmof.Ccnlftcam0occupanry. DSignature of Applicant Date
2-24-
Own n bm.gS D„e All roof coverings to be Class "B”or better
G &a-
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