05010058 CITY OF CUPFRTINO
BUILDING DIVISION PERMIT CONTRrACT®RxINT+ORMATION
UILDING ADDRESS: BAY AREA CONTRACTORS CORPO JNO05010058
NER'S NAME: PERMITLSUE DATE
ONE: SANITARY NO. CONTROL NO.
ARCHITECT/ENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
0 0 0
+00 LICENSED CONTRACTOR'S DECLARATION'
£ F I hereby affirm that I am licensed under provisions of Chapter 9(commencing Job Description
i� wiN Section 7gX77 of Division Sof the Business atM Professions Code.end myliccnse is
±�„ immllforceandefmC1. REVISION--IN HOUSE USE ONLY
a y2 z License Class Lic.N
Or ARCHITECTS DECLARATION Datac°"DNO NEW PERMIT ISSUED/ORIG. #04020172
EC
E�U I understand my plans shall W used as public records
s o N Licensed Professional
S OWNER-BUILDER DECLARATION
<S1 acres,affirm dual 1 am exempt from the C"ntracmr's License Law for IW
pO following reurn.(Seeuun 71BL5,Business ado Professions Code:Any city or county
5 m� which requires a permit to construct,alter,improve,demolish,or repair any,stmemre
_iy poor In Out issuance.also requires the applicant for such permiuo rile a iignedsmtemcni
e o that be,is licensed pursuant to the previsions of she Contactors Licenselaw(Chapter9 Sq.Ft.Floor Area Valuatio�g115
2 (commencing with Section 7(100)of Division 3 of the B usiness and Profusions Code)or
��$ that he is exempt therefrom and the but for the alleged exemption.Any violation of
Section 7831.5 by atry applieun for a permit subjects the applicant to a civil penalty of APN Number Occu ane-Type
not mom than fin hundred dollarsS50d. - p y yp
I,at owner of the pmpeny.or my employees with wages at their sole compensation, 37534060 . 00
will do the work,and dte swctum is not intended or Offered for sale(See.VDU,Business
and Pmreselons Code:The Conmete,'$License Law does not apply toan owner of Required Inspections
property,who builds or improves thereon.and whodoes such work himself orthrough his
Own employees,provided that such imp own enu are not intended or offered for sale.If.
however,the building or improvement is sold within one year of completion.Ne owner.
builder will have the Wrticn of proving Nat he did not bold or improve far puryose of
sale,).
0 I.as owner of the pmpeny,am exclusively contracting with licensed contractors to �\
ct9;;4
the pmjem(Sec. an owner
antlnywhoipui Code:)The
ns Bacteria.
Lid \
not apply to an owner of pmpcny who builds or improsOn thereon,antl.
who contractsch projects with o conlnemr(s)licensed pursuant to the Canmclors
der Sce. _ ,BhPCf rth' peM1
7'-m o a 5O 'SC ENSATI D ATION
i underputaltyof perj one Idtefollowing declarations:
I have and will maintain a CeniGeate of Consent m self-insure for Werker'a Compen-
sation,u provided for by Section 3700 of the tabor Codc,for the performance of the
work for which this permit is issued.
l❑I have and will maintain Worker's Compensation Insurance,u required by Section
3700 of the labor Code,for the performance or the work for which this permit is issued.
My Workers Compenvdon Insurance carrier and Policy number art:
Comer. Policy No.: _
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE .
17TH accuse sed nos becompletesl if Ik permit is forone hundred dollars(SLOB
or less.)
1 certify Thal in the performance of the work for which this permit is issued.1 aball not
employ any man w mbecome wo "'theworkers'Compcnsation
4pp
of Califon y t-7( -� /
es. .UA/n_ ._//M //
CE .If attar making Thu Cant))am o cmpton,you should
ubjeet m the Worker' Compcuetion provisiObs of the labor Code,you mail
Oith comply with web'prnvisirno or this permit shall be deemed invoked.
Z'N CONSTRUCTION LENDING AGENCY
1 hereby affirm that mere is a construction lending agency for the performance of
X thc work for which this permit is issued(Sec.3097,CO.C.)
37 Lenders Name
z Lenders Address
U O 1 Mortify that I hale read this application and sum that the above information is
FCOMM.l agree to comply with all city and county cohninces and state laws relating to
U building Construction,and hereby euNofire rcpresenutins Or this city to miser Upon the
W above-mentioned prpperty far inspection purposes. a r'�,
0.r (We)agreeConsequence
of m save,indemnify antl keep harmless the City or Cupertino against ( l / lJ
h liabilities,judgments,costs and expenses which may in any way aecmo against wid City 1
U z A APPLICANT
of the Braining of this permit.
APPLICANT UNDERSTANDS AND WILL COMPLY WITN ALL NON-POINT Issued by: Dale
S U, ULATIONS.
/U oS' Re-roofs /
Si Lure p man cor �^ Date
H ARDOUS MATERIA D l_O'kU E� Type of Roof
Will the appile rat Lir(alum Wilding occupant vase or handle hanmuos material
fined by the CUpenum Municipal,Code.Chapter 9.12,and the Health and Safety
c.SO yes No 25532(e)?
❑tin All roofs shall be inspected prior to any roofing material being installed.
Will the applicant o fumrt building Occupant use equipment ordcvices which If a roof is installed without first obtaining an inspection,I agree to remove
it havard"us air contaminants at defined by the Bay Area Air Quality Management all new materials for inspection.
isUlm?
❑Yn
I have mail the hma (smaterialsrequimmeats undcr Chapter695 ofthe Califon
' Health6Safc,codc,Sm..25505,25533 am125534.1 On dmat if the Wilding
dyad t spread Y haat a tenant that it u my res wbiliryao Duty irks acupanl of the
mQ/ 6u bkM1 List be sectprionuisex is ertir moraeaRanq,.L) S Signature of Applicant Date
l
o aerorwmorind iltent I, Da All roof coverings to be Class "B"or better