05030155 CITY OFCUPERTINO w r„ � �+� • rW,
BUILDING DIVISION PERMIT Fol 'R 'QR`T ^`ATIW
BUILDING ADDRESS: PERMIT NO.
05030155
1 29:71 NRWSOM AVE
OWNER'S NAMR: PERMIT ISSUE DATE
E; SANITARY QftOL NO.
ARCHITECEMNOINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
p
+toij LICENSED CONTRACTOR'S DECLARATION
I hereby affirm that I am licensed under pmviumu of Chapter 9(commencing Job Description
Pel with Section 7")of Division 3 of the Buuwa and Pmfcshmx Code,and my license It
I.full force antl effete.
5i*z License Clara Lk.0 ADD 2ND UNIT 498 '
Date Contractor
e ARCHITECT'S DECLARATION
Y I undeNend my pklu'hall he used as public mcards
36
sed Lkeued Pmfcecionu
OWNER-BUILDER DECLARATION
0 Z 1 hereby.Rete on 1 1. exempt from she trusi ns Co License Law for NC
following reason. (anis t 710 L0. t,alnna and w.de nee h,or Any city s county
E:00$ which sequima•permit fo enluvucs Blue improve,demolish,ri e a sig any structure
`i^ prior In its ienentgAlan mant to the
pOwi.ltant(m such Permit to ie saiLaedststcmcm
�< that hakceenwit punuant 7000)of Division
ivisionf thea Business
Code)or Sq.Ft. Floor Area Valu hon
(commencing exempt
Section 7011 d of Divui far of the
alleged
ear enders.My
I*Uoa of
Net io k camps therefrom and de per for IM cut he eumant I.My it Penalty
of
not
more by airy applicants(a permit mbfema the applicann...ivil peulty of p y T,pe
not mart Nan rise hundred dollars(f300L 3 �er00 Occupancy .!!
0 Laowror ofthe property.«my employees with wguuHeir wk eompenmlon,
will do the work,and themucure k not intended ar offered for aek(Sec.7044,Busineas Required Inspections
and Profcaku Code:The Conuanoh Liceae law does bet apply a an owner ns of q p
property who bei ldi m Impmes Ihareon,and who deeuuch.,it himself or duuugh his
own employees,provided that such Improvements see not Intended reoffered fornle.If.
howeser,the building or Improvement is sold within aro year of completion,the owner-
builder will have flat burden of proving Out he did not build or Improte for purpose of
ark.).
❑1,as owanr of the property,am emluivcly contracting with licensed['macron to
construct the project(Sec.70,11,Business and Profusions Code:)M Commune,U.
canesLA.does not apply uan with
ofproperly who buildsor Imposes Couranand
such
who contracts far eM1 proprojectscwIN a tonuactor(s)licensenmthe d puuuo Conmacloh
License Law.
❑temexempt antler ,BA PC for this resew
Owner r a. Data Al
WORKER'SCOMPENSAMON DECLARATIONlip
I hereby grim underpnsityofperJury oneofthe following dradarations:
❑Ihsve and wlllmsinulnaCeniMete of Cauemmself-Inmmfa Worket'Compen- v7{/'!ryV/L
antlen,u povldetl 00 for by Section 37of the labor Code,for mIlse the performance of Er y
work for which%io permit is iaued. dA 1tL'
❑1 have and will maintain Workers Compensation Inannnce,as required by Section '(y\`'�✓�`+
3700 of the labor Code,fur the performance of the work for which this permit is Word.
My Worker',Compensation Insunnee carrier and Policy number em:
Caller: Policy No:
CERTIFICATE OF EKEM MON FROM WORKERS' '
COMPENSATION INSURANCE
(This action reed not Mcomplucd If the Permit Is far one hundred dallan($I(p)
or lees.)
1 certify that in the performance of the work for which this Permit Is Issued,I shell not
emplay any Personin any m reran u to becomembJeci to the WorInta Compensaikn
Law.of California.Dam
Applkent �•'" ..a --
NOTICE TO CANT:IL after mekinj Nit Can ricuc of Exemption,you should
hocome mhJe to the Woder'a Campaatlon PlOnhi ll Of the tabor Cade,you must
.J 0 forthwith comply with such pmvivons m this permit shill he deemed revoked.
Vy CONSTRUCTION LENDING AGENCY
r[r I hereby affirm test there les commucdppnc
on lending for the Performance of
,yin Ne work far which this permit la!LYed(Sec.3097.CIN.C)
Q Leads".Name
O z Lendu'a Addreas
U O 1 cenify,Nu I have reW this application and state that the abom information is
D.F correct.l agree to comply with all city and county ordinance'and area laws misting to
OU building eoreslmetlon.and herebyeutharm rcprcunu0ws of this city to enter upon the
l[7 above-men iced property for Inspection purposes
(We)agree to love,indemnify and keep harmless the City of Cupnina agaiat
IZI Ilabilitha judgmenu.com and expense which may In any way acme against aid City
mccU�+ APPLt CANT UNDERSTANDS tANthis
AND WILL COMPLY WITH ALL NOWPOINT Issued by: Date
SOURCEREQUL 115.
Re-roofs
SiLnaturc of AppliuMCamrac Date
HAZARDOUS MATERIALS DISCLOSURE Type of Roof
Will the Applicant or fuure building occupant atom or handle huudau meudai
u defined by the Cupertino Municipal Code,Chapter 9.13.and the Health and Safety
Cade.Section 25532(s)? All roofs shall be inspected prior to any roofing material being installed.
❑Yes ON.
Will the applicant or factum building Occupant use equipment ordew=which If a roof is installed without first obtaining an inspection,I agree to remove
telt harammu.air canumNan r u de0fod by the Bay Area Air Quality Management all new materials for Inspection.
District?
❑Yes 0N
I have rad the havudfos materials requirements under Chapter 6.93 of the Califor-
nix Health k SafetyCode,Sctiau 25503.25533 and 25511.1 undcmantl NU lftie Wilding
does fol currently hare a tenant,the It k my reAPenINIily b beauty the occupnl of the
requirements" Ir nbcmetpkrmwrneecar.Ccrtirm.terrGctapumy. Signature of Applicant Date
owntr Chonmdagent Data All roof coverings to be Class"B"or better