04030233 CITY OF CUPERTINO
BUILDING DIVISION PERMIT C- NTRA1 kT0-A- N%xtIVTATION,
Bu1LOlNGADDTOM MCAURTHER CONSTRUCION PERMITNo
MT .04030233
ONE
R'S NAME: PERMIT ISSUE DATE
ANAT
NE: SANITARY OL NO.
ARCHITECT/ENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
0 0 0 0
Lop LICENSED CONTRACTOR'S DECLARATION
Job Description - - -
1 hereby afftrm that 1 am licensed under p rneisioaa of Chapter 9(commencing - - -' _
with Section 70Th)of Division 3 of the Business red Professions Code,and my Iieenu is _
b t2 d in full force sod)Rett.
q"b License Class Lte.x REVISION- BAY WINDOW
Dam Cmamclor RMIT ISSUED ORIG. #03110136
ARCHITECTS DECLARATION
�i 1 ond)manJ my plans shell he wed as Puhlie rareds
�yU
3 c Licensed Pmfessinnel
OWNER-BUILDER aseraDER DECLARATION
I hereby maso affirm that 1 1. exempt from the Conwutoh License c Lew for the
p O following mason. etc(Section co LA addresslaland ve.de ow Calc:Any city or county
$ which requires issuance,permit re ennswct,aha ice forSu demolish,rie a Sig ed struu ni -
iiathat mitsensdpalso rc tot he the applicant far suchPermit tocoasignmistotemcm
he s licensed pursuant 70th ofprovision ofthe eBuiness Licenu law(Chapter 9 Sq.FL Floor Area Valuati QAl07
q t $ atheIs(commencing with Section]and of basis
3 of the al egad ca and Preon.Any
Code)or
'7
IC�.. that he V eumpt therefrom end the buts for the alleged eumption.Any Wolation of
Section 7031.5 by any appliunt for a permit subjects the applicant to a civil penalty of AAFN Number Occupancy Type
not more than five hundred dollars(5500).
01,u owner Orton property,or my employes with wages as their sole Compensation, 35702042 . 00
will do the work,and theswcture is nolinlended oroRered forsam(sec.7044,Business
and Professions Code:The Conuactoes License Law dors not apply m an owner of Required Inspections
Property who builds or tm provesthereon.and who Odes such work himself or through his
own employees,provided tha,such improvements are not intended aroaercd forsals.IL
however,the building or improvement is sold within one yesr of completion.the owner.
builder will have Na border,of proving that h did not build Or improve fns purpose of
sale.). /
.Pq 1,as owner of the property,am exclusively contracting with licensed contractors to O
wnstrucl the project(Sec.7041,Business and Professions Code:)The Contrutora Li.
cove law dors not apply to an owner of property who builds or improves thereon.and
who Contracts for such projects with a comounhKB licensed pursuant to the Cantrutor's
Licenu law. ✓v\
❑1 am esemp,under Sec. .B&P C for this mason
r Date
WORK C PENSATION DECON
I hereby a01 ruder Penalty of perjury mw o the f ing dechostions: -
I have end will ma nW n s Cen rimM of Consoni to ulf-insum for Worker'sCompen-
sation,u will for by Section 3700 of Ne later Code,for the pe&a m.of the
work for which this permit is issued.
0 I have and will meinWn Worker's Compensation Insurance,ss required by Section
3700 of the Labor Code,for the performance of the work for which this permit is issued.
My Worker's Compensation Insum oe carrier and Policy number am:
Carrier: Policy No.: _
CERTIFICATE OF MEMPDON FROM WORKERS'
COMPENSATION INSURANCE
(Thissectim need not h completed Btie fermi,is Intone hundred dollars($100)
nrless.)
1 cenify that in the performance of to work for which this permit is issued.I shall no,
employ any person in any manner an as to become subject to the Workers'Compensation
Laws of California.Dam
Applicant
NOTICE TO APPLICANT:If.after making this Cernficalo of Esemp,im,you should
become subject to the Workch Compensation previsions of the Labor Code,you must
Jz foMwith comply with such provisions or this permit shall be deemed revoked.
'Z O CONSTRUCTION LENDING AGENCY
(-r I hereby affirms Nat there is a construction lending agency for the Performance of
6:7 dte work for which this permit is issued(Sec.3037,Cl,C.)
GQ Lenders Name
z Lender's Address
V Q 1 certify that I have mad this application and mute that the shore information is
Lir E' Cormet.I agme to comply With all city and county on inmces and sum laws relating to
O t.7 building construction,and hereby aulbonm mpreunmives of this city to enter upon the
r W ahovn(Weia ood gree to mnysave fordamnify an keep ha
(We)agree to Cove,indemnify and kith hay in m 0e City of Cupertino against _ /
U raA in
judgments,ceofte gralEiand expenses which may in my way aeeNC against E°Id City
V 7 in consequence of the granting of permit. '
�i APPLICANT UNDERSTAND AND WILL COMPLY WITH ALL NON-POINT Issued by: Date
SOURCE REGULATIONS.
3 26 a" Re-roofs
g wrc ofAppli A° DOUS MATERIALS DISCLO Data Type of Roof
Will applicm orfuture building Occupant store or handle hmndous material
defined by the Cupertino Municipal Cade.Chapter 9.12.and the Health and Safety
ade,secdez25532s)?❑Ye, NN. All roofs shall be inspected prior to any roofing material being installed.
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
mit hawrdnus air conmminanu as defined by the Bay Area Air Quality Management all new materials for Inspection.
District?
0 Yes No
I have mad the he"O nus materials nuf iremcnto under Chapter 6,95 of the Califor-
niaHealth&Safely Cade,Small^5505,25533 and 25534,1 understood that if the building
docs not currently have a tSqa that it is my responsibility to and I the occupant or the
quimme°uvwhi)hm srb' onL Wumaaracertincam orOccup.ry 3 6/ Signature of Applicant Date
u
e,ter r d ret te All roof coverings to be Class "B" or better