04080026 CITY OF CUPERTINO *"•` ^� '
BUILDING DIVISION PERMIT CONITRAGTfiR INFORM-ATI0N
BUILDING ADDRESS: PERMIT NO.
04080026
OW NER'S NAME: PERMIT ISSUE DATE
KNALED SANITARY OL NO.
IDNE: SEP 6 1004
HITECfIENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
E t�
Z, LICENSED CONTRACTOR'S DECLARATION Crl t10n
C I hereby affirm Net I am licensed under previsions of Chapter 9(commencing P
b with Section 7")of Division 3 of NC Business and Professions Code.and my license is
Licenlse Clater;
effect
Lick PER GREG: CUSTOMER TO
Dam Contractor PAY $671 . 99 TO GET FINAL
W ARCHITECTS DECLARATION
yy 7 Iunderstand myplans shall the used aspublic records INSPECTION FOR PREVIOUSLY EXPIRED PERMIT
Y�U
;p y Licensed Pmfcssimul
3 OWNER-BUILDER DECLARATION
I 1 hereby alfirm Nm 1 em exempt fnm the Contmemra License Law for the
o 0 following mason.(Section 71131.5.Business and Professions Code:Any city or county
K m V which requires a permit to cnnstum,elle,,improve,demolish,or repair any muctots
an 'o prior to its issuance,also requires the applicant for such permit to Ile aligned statement
=a that he is licensed pursuant to the previsions of the Connector's LicenseLaw(Charter 9 Sq.Ft. Floor Area Valuation
(commencing with Section7g10)of Division 3 of the Business and Professions Calc)or
ey.. Nat he is exempt thomfoom and the basis for the alleged exemption.Any violation of
Section 7031.5 by arty applicant for a permit subjects the applicant m a civil perdty of APN Number Occupancy Type
not mom than five hundred dollars($500).
r.
❑1,as owner of the property,or my employcu with wage.u their sole compensation,
will do the..,it,end the swaumis not intended oroRertd Tarsale(Sec.]044.Business 36929009 . 00
and Pearn sians Code:The Contractor's License Law does not apply to an owner of Required Inspections
property who builds or improves themon,and who does such work himself or through his
own emphymne,provided that such improvements ere not learned or offered for sale.If,
baweve,,the building or improvement is sold within one year of completion,the owner-
builder will have the burden of proving that he did not build at improve for purpose or
sale.).
❑1.as owner of the properly,am exclusively contouring with licensed contractors to ,
Conswct the project(Sec.7064,Business and Professions Code:)The Cannot.,.Li.
cense law does not apply to an owner of property who Wilds or improves thereon,and
whoconl wosformwhpmjcctswithacon aaor(s)liccnud pursumuo the Contanar's
Law.
1 rept under jee. .B&PC ar this mason
Dan¢
WORKER'SC MPE A NOEC RATION
hereby starts under penalty of perjury one of the following declarations:
have and will maintain a Certificnm of Consent m self-insure for Worker'sCompen-
m provided for by Section 3]011 of the Liters,Cade,for the performance of the
for which this permit is issued.
1 have and will we
Worker's Compensation Insurance,as required by Section
3700 of the Labor Code,for the performance of the work for which this famous is issued.
My Worker's Compensation Insurance canter and Policy number am:
Cartier. Policy No.: _
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(This section need not W completed if the Permit is for one hundred dollars($19))
or less.)
1 certify Nat in the perfo ce of Ne work or hich Nia Permit is issued,1 shall not
employ any pe nmany nner so as to bac me object the Workers'Conerse tion
Laws of Calif 11r c r
Ap cam r
N TO APPLI NT.If.after making this Certificate of Exemption,you should
b subject to th W9rkch Compensation previsions of the labor Ccue,you must
.J 2• forthwith comply wilMSGch provisions ar Nis permilshall Wdecmctl revoked.
Zi O CONSTRUCTION LENDING AGENCY
'r. I hereby affirm that there is a Construction lending agency for the peffurmmtt of
pa. r7 the work fur which this permit is issued(Sec.3097,Civ.C.)
W�A landcr's Name
z Lenders Address .
L)0 1 certify th l 1 have read this application and now the,the above information is
IL,P correct.)agree to comply with all city and county ordinances and spite laws miming Io
O V building construction,and hereby authorim represenmrives of this city to enter upas the
4S1 shave-mentioned property for inspection purposes.
gy (We)now,m rave,indemnify and keep harmless the City of Cupertino against
tiCA liabilities,judgments,cosh and expenses which may in any way scenic against said City
U I in consequence or the gmming of Nis EcLmit.
r-•tI APP ANT UNDER ANDS D WILL COMPLY WITH ALL NO -POINT Issued by: Date
5 U E REGULATI NS.
J Re-roofs
re o pplraaHdAZARDOUS MATERIALS DISCLOSURE Type of Roof
Will Ne applicant or future building account store or handle haardous material
ad..
by IW Cupertino Municipal Code,Chapter 9.12,and the Health and Safety
dc,Section 25533(x)1 All roofs shall be inspected prior to an roofing material being❑Yes No P P Y g g installed.
Will the applicant or future building accupam use equipment or devices which If a roof is installed without first obtaining an inspection,I agree to remove
it hamrdous air contaminants as defined by the Bay Area Air Qual its Management all new materials for inspection.
in?'
❑Yes
1 have mad the havardous materials requirements under Carrier 6.95 or the Calif n.
nix Hcal"Safety Code,Sections 255():8533 and 25534.1 underamad Nat if me building
does tot-c"umendy have arGrant,thm u my responsibility to mm actuant of the
m immc -wmrn sthbm
Pont
Tac ncateeunanp� Signature of Applicant Date
ter aamrsr(vad.gen, ZS l/ Dam All roof coverings to be Class "B" or better