05050016 CITY OF CUPERTINO
BUILDING DIVISION PERMIT ' CONTTRAC-,TOR INFORMATIO,N ,-
BUILDING ADDRESS: PERMIT NO.
05050016
OWNER'S NAME: PERMIT ISSUE DATE
F LAT
E: SANITARY OL NO.
ARCHITECT/ENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
0 t�
uoppLICENSED CONTRACTOR'S DECLARATION Job Description
with
d C W
1 hemby affirm t I,m licensed under pmvoP
iumat of Chapter 9(commencing
t' Section 7f(U)of Division 3of the Business AM Professions Carle,and my license is
^ o, in full force and effect
?�= License Class Lie.# REVISION--RED LINE S-2
—o Date Contactor NO NEW PERMIT ISSUED/ORIG. #05030155
p ARCHITECTS DECLARATION
An
y1 understand my plans shall be used As public mcmds
� U
;oG Licensed professional
3 OWNER-BUILDER DECLARATION
+�0 0 I hereby affirm that 11. uemps from the Convactor's :Any c Law far thin
Q o fallowing mason.Permit
)(131.5,Business and ive.dcinns Codr:Any city or county
�r m which myvimt a permit so construct,..thaalar,improsu h Permit
of e pair ed ssacmre
thin M I,l issuance,also requime thvetai sof far mchpctmr mf0e.Lawdauitemcm
intharhcuccemcdpursuanuothe pmviviomofthe Canuiness Liconxlaw(Chapter 9 Sq. Ft. Floor Area Valuation
FFG that he ncingwiNSection
rion 7000)ofbasisofra(the Business and Profession Any vi CMc)of 0
y�$
that he u eumpt therefrom and the basis for the alleged exemption.Any violation of
Section 7031.5 by any Applicant fora permit subjects the applicant In a civil penalty of APN Number Occupancy
not more Nan five hundred dome(5500). P y Type
❑Lasownerooshepmpeay,ormyemploycmwithwagontheirulccompenx0an, 37532001 . 00
will do thework.and Ne swcturt is not intanded or offered forsalc(Sec.1044.Business
and Profesmom Code:The Coouxmr',License law dors not apply in an owner of Required Inspections
pmpeny who buildsor improves dmrcon.and who doessuch work himxlfor through his
own cmpin mm.provided that such impmuments art not intended proffered for sale.If.
however,the building or improvement is sold within arc year o(completion.she owner- \ O
builder will have the burden of proving that he did nos build or improve fm purpose of
tile.). \�
❑1,as owner of the property,am eAchramly contracting with licensed contractors to m\
construct La dm es Subject apply
in in Business and rry w1
0 bun Code:)The Condemns Li- \�
came taw dors not apply b an owns of property Who builds or Improves demon.Comment's and
whocontractsLaeu for such projects with a conuacmr(s)lianxd pursuant w dte Conuutoh
L'rcnmtaw.
❑lam exempt under Sec. B&PCfor Nu mason 77 �
Owner Dao 7
WORK 'S COM NSATION DECLARATION
1 hemby affirm un er penalty of pat ane of the following declarations: .
El 1 ham and will maintain a Certificate of Canons to self-iaeum for Workres Compen.
some,as provided for by Section 3700 of the Labor Code.for the performance of thin
work for which this permit is issued.
❑I ban and will maintain Workors Compensation Insurance,as required by Section
3900 of the labor,Code,for Ne pmRawanm of the work oaf which this permit is issued.
My Warkch Compensation I..aHim and Policy number art:
Camey. Policy No.: _
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(Thu scesim need not accompanied ifshe permit is fm one hundred dollaa(SIM)
or loss.)
I cenify that in she performance of the work for which this permit u issued,1 Nall not
employ,any perm in any manner x in in become subject to the WoAcfi Compensation
Laws of California.Data
Applicant
NOTICE TO APPLICANT:If,after making this Certificate of Exemption,you should
become subject m the Worker's Compensation previsions of dm labor Cade,you most
.,O forthwith comply with such Provision or Nis permit shall be deemed ranked.
Z h CONSTRUCTION LENDING AGENCY
[—r Ibembyofrirm that them is a cmrssructian lendin,,one,fofthe pe,fmmam eof
p:7 the work far which this permit is issued(Sec.W.Civ.C.)
ALendcrf Name
z Leaders Addmu
U C) I certify that I have read this application and suite Nn the above information is
U, P MMOL I agora to comply with all city and county oNinmces and state laws misting to
0U building corswaion,and hereby audiorm,mroammatim;of this city to enter upon the
4 flit alovomcnudgm pmPcny for impaction purposes
(, e. (We)agree m save,indemnify and kmcp harmless the City of Cupertino against
ti incaitie;judg,of
o,tsAnd g Cxpemesraft. may in any way urnsc against mid City
U z A APPLICANT
of UNDERSTANDS
this pct mit.
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT Issued by: Date
SOURCE REGULATIONS.
Signature o/ApPlicaData
Re-roofs
HAZARDOUS MATERIALS DISCLOSURE Type of Roof
Will thee Cupertino
lmufebuilding e.Cuhapteroseor handle Heald,and
As de.Sn by oushe Cupertino Municipal Carle.Chapter 9.12.and the Health end Safcry
Code.Section 25531(x)?
❑Yas ❑Nu All roofs shall be inspected prior to any roofing material being installed.
Will the.pPhrml or comm building ocmpot ose equipmm aor device,which If a roof is installed without first obtaining an inspection,I agree to remove
miI hazardous ai,corumimmu as declined by the Bay Area Air Quality Management all new materials for inspection.
District'
❑Yes E:]No
I have mad Ne harmlaus materials mquimmenu under Chapter 6.95 of the Cahlor-
-in Health&SafetyCode,Sore.35505.25577 and 25534.1 undersand Nuboom building
dors not cum Iyh.'ry amount,that Il u my mmmoibilay mratify thin memorm of oe
requimments which rggst In ma arm its cc turn CrniOemc araFry ; o ySignature of Applicant Date
fy 'a
Owmro,authmi d.gem Dam All roof coverings to be Class "B"or better