04060040 CITY OF CUPERTINO ,z, '
BUILDING DIVISION PERMIT �U1"'i11RA�.'C?I, •"Xl ' � T.XON'",�'
BUILDING ADDRESS: PERMIT NO.04060040 4060040
OW NER'S NMEAPERMIT ISSUE DATE
T;ESANITARY OL NO.
ARCHITECT/ENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
+fop LICENSED CONTRACTOR'S DECLARATION Job Description
+O 1 hereby affirm Nat I am licensed under provisions of Chapter 9(commencing
with Section 7001,ofDiviaion 3 of the Beat..and P.(.Wona Coda,and my license is
^ in full force and effect.
License Class Lic,0 ADDITION/STORAGE
Dam Conlracbr
9 ARCHITECTS DECLARATION UPGRADE ADA BATHROOM
I understand my plans shall be used As public records
3 777
cad� Cleaned Professional
OatNE0.-BUILDER DECLARATION
0 0 I hereby alrmm that 1A.1. exempt from the Contractor's Licence Law for the
00 fallowing renon. arch h 7031.6.Business and Improve.
egoli Code:Any city m county
$ which myui.a a permit re rnmweL ai.n W for such
demolish lir repair any structure
z t„^ prior it)its issuance.purse requires the applicant for Contractor's
Lima.
(chapter
chs ter9
ggpp< thatnt
helicensed Seen..70th)ofDiilonn(NcCanuacloriLicenseLaw(C Code)
Sq.Ft.Floor Area Valuation
aF$ (cat he
gent, Semian 7000)of Division of Neegeinexempton.nyvi Ction of
•. Nu be b exempt therefrom and de bub far Ne alleged exemption.Any violation of
Section 7031.5 by any applicant for a permit subjects than applicant in a civil penalty of APN Number Occupancy Type
not more than Rw Nommd dollars($500).
❑1,As owner of the property,or my employees with wages As their sole compensation,
willdothcwork.andtheawctumisnotinlndedmo0e.dfunale($n.7044,Buainu ns 36218010 . 00 Required Inspections
and Profemimos Code:The Communes Licene Law don not apply in in owner of q P
property who builds or improves themem,and who do es such wank himself or through his
own employ=.provided that such improvements art notintended at offered for sal.If.
however.the building or improvement is sold within aro year of completion,the awter-
builder .will have the burden of proving that he did not Wild or Improve for purpose of
Ale.).
❑1,as cower of the property.am exclusively contracting wit licensed cont a ars to
construct the pmjnt(Sec.7044,Bareness and Pretensions Cade:)The Conuacmr's U.
acne Law dace not apply to an owner of property who Wilds or Winews thereon,and,
who contracts for such projects with a contncmr(s)licensed pursuant.the Contractor's
License Law.
❑l am exempt under Sec. ,B&P C for this reason -
Owner Data -
WORKER'S COMPENSATION DECLARATION
1 hereby affirm under penalty of perjury ane of the following declarations:
I hem end will maintain a Certificate of0onem te self-inn.far Warkees Compen.
cation,u provided for by Section 37W of the Inbar Code.far the performance of ft
work for which this permit is issued.
❑1 have and will maintain Worker's Compensation Insurance.as required by Section
31W of the Labor Cade,for the performance of the work for which this permit is lowed.
My Worker's Compensation Insurance carrier and Policy number am:
Cartier: Policy No.:
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(Thbsection need not W completed fine permit 11 fmaoohundred dollen($100)
or iii.)
1 certify that in to performance of the work for which ths permit is issued.I shall nut
My any person m manner o, becomen neo the Worten'ComPenation
Laws of Cal' mi
Applicant ef,4yt
NOTICE TO APPLICA f,After making this Certificate of Exemption,you should
become subject 10 the Woheri Compensation previsions of Ne Lagar Code.you most
,J 0 forthwith comply with such provision or this Permit shall W deemed rooked.
zCONSTRUCTION LENDING AGENCY
sr� Ihereby afern that them is aco.uuctinn lending agency for the performance sof
fY 7 the work for which this permit Is issued(See 3097,Civ.C.)
[Ll Q fender's Namc
a z Lender's Address .
U 0 1 certify that 1 haw read this application and ante that the above information Is
W F correct.I agree to comply with all city and county ordinances and atem,laws totaling.
fit, building construction, ix ction,and hereby and mpreaenmivn of Nis city to enter upon tie
U above-mentioned property for inspection purposes.
C (Wc)agree.Ave,indemnify and keep harmless Ne City of Cupertino against
Trp liabilities,judgmemu,casts and expenses which may in any way accrue against mid City
fJ 7 in consequence of to grAting of this permit.
r7 APPLICANT ODERSTANDS AND W L COMPLY WITH ALL NON-POINT Issued by: Date
SOUR ADONS. �•
2-:: � i T a t Re-roofs
Signature ofAppli cnuactor ��Da.
HAZARDOUS MATERIALS DISCLOSURE Type of Roof
Will ft applicant or future Wilding occupant gore ar handle hamrdous maldg
As de0ned by the Cupertino Municipal Code.Chapter 9,12.and the Health and Safely
Code,Section 25532(a)? All roofs shall be inspected,prior to any roofing material being installed.
❑Yes fgNu
Will de applicant or future Wilding occupant use equipment or devices which If a roof is installed without first obtaining an inspection,I agree to remove
I bandanas air contaminants u defined by the Bay Area Air Quality Management all new materials for Inspection.
strict?
❑Yes XNu
I have mal the hamtdousmalriatsrequirements under Chapter6.95 arthe Califor-
nia Health&SafetyCode,Sectiore25505,25533 and 25534.1 understand thatifdre Wilding
docs not current ave a tenant,Nat it b ponihii hit an nndfy the occupant of the
rc i must bemmpnor b CCohCeNfKBICofQcupNry. Signature of Applicant Date
'"`���7 i 4o,�e, All roof coverings to be Class"B"or better
Owner or authoriv agent Date
C