04060175 CITY OF CUPERTINO
BUILDING DIVISION PERMIT EQ�1`•�R� T� `x _ ON
BUILDING ADDRESS: PERMIT"04 060 1 5
OWNER'S NAME: PERMITISSUEDATE
S
Eo SANITARYO. CONTROL NO.
ARCHITEC(ENGINEER; BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
0 0 0 0
+00 LICENSED CONTRACTOR'S DECLARATION lob Description
1 hereby affirm Nat 1 an licensed under provisions of Chapter 9(commencing P
will Section 7IXYJ)of Division 3 of the Business and Profcasions Code,and my license is
fu0mrteandeffect. TI--DENTAL ALLS
-�� Li DOORS/ INSTALL D
m Z License Clue Lie.p r
ze� Dam COMmuser OPENINGS W l ELECT. )
ARCHITECTS DECLARATION
Y R U 1 undersand my plans shall be used n public mentis Q
3Qo Licensed Professional SEP r® 2004
S OWNER-BUILDER DECLARATION
1 hereby alarm that 1 um exempt from Ne Comnacmr'a License Law for the
F.F.O O following mason.(Section 703 L5,Business and Professions Code:Any city or county
$ff which requires a permit to construct,alar,improve,demolish.or repair any suuctum
F
poor it)i%issuance.else requires the applicant forsuch permit to file a signed statement
s�s< thatW is licensed pursuant mthe provisions of the ContracmrY License law(Chapter 9 Sq. VahT§I 000
yF$ (commencing will Section 70DO)of Division 3 of the Business and Professions Code)or v
�..
that he is exempt therefrom and its,basis for the alleged exemption.Any violation of
Section 7031.5 by any applicant for a permit subjects Ne applicant to a civil penalty of APN Number Occupancy Type
not mar Nan 0ve hundred dollars(5500). t .
❑1,as owner cribs proprny,army employ=will wages as their sole compensation, 36940021 . 00
willdo the work.and the structure is notintendsd woffemd forsale(Sec.7044,Business
and Profession mrn
Code:The Coacmes Lt..Law donot apply m an Owner of Required Inspections
property who builds or im prows Hereon,and who does such work himself car through his
awn employees,provided thmsuch improvements are notimanded or offered formm.If.
howeve,,the building or improvement Is mid within one year of compledon,the owner-
builder will have the burden of proving that he did not Wild or improve for purpose of
vele
1,as owner of the property am exclusively contracting with licensed contractors to
concoct the project(Sec.7044.Business and Prfnsions Code:)The Contractor's Li-
cense law does not apply to an owner of property who Wilds or improves thereon,and
who convects for such Injects withacont l6gQ licensed pursuant to the Con"cus's
License Law.
❑lam exemp/t ur�t� ,B&PCT rill cera
ow r Dau
WORKER'S CO ENSATION DECLARA N
1 hereb an
era penalty of perjury one of she follow declana0on:be ad will maintain aCertificam of Consent to self-insum forworker'sCompcn-
on•as provided for by Section 3700 of the labor Code,for the performance of the
work for which this permit is issued.
❑1 have and will maintain Workers Compensation Insurance,as required by Section
3700 of the labor Code,for the performance of the work for which this permit is issued.
My Workers Compensation lnmmnce carrier and Policy number am:
Cartier: Policy NO.:
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(Thu section need not W comphoed Lf the permit Is foronc hundred doilam($140)
or less.)
1 certify that in the performance of the work for which this permit is issued.l shall not
employ any person in any reactor so as in become subject to the Workers'Compenmlon
Laws of California.Dais
Applicant
NOTICE TO APPLICANT:if,after making this Certificate of Exemption,you should
become subject to the Wotkats Compensation provisions of the lahnr Code,you must
Q forNwins comply with such provisions or this permit shall W deemed mucked.
rh CONSTRUCTION LENDING AGENCY
[r Ibarely M.that Nem is a concoction lending agm¢y for,he performance of
tai 7 the work for which this permit is issued(Sec.3097.Civ.C.)
WM Q Lender's Name
.7 z Lender's Address
U 0 I codify Nat 1 have read this application and sus that the above infarmmion is
D.F cared.I agree m comply with all city and county ordinances and sure laws relating to
0U Wilding construction,and hereby nonsense repriumnativ*es of this city to enter upon the
[37 above-mentioned property for inspection purposes s
(We)agree to save,indemnify and keep hnrulem the City of Cupertino against
mFi raA liabilities,judgments,costs and expenses which may in any way accrue against mid City
U Z in consequence of the gaming of His permit.
^^ APPLICANT UN 5 AND L COMPLY WITH ALL O POINT Issued by: Date
SOURCEREG .� n (`
V 7 Re-roofs
Sig fApllmanOCon"clor
HAZARDOUS, ATERIALS DISCLOSURE Type of Roof
mentor umm building occuponatore or handle havatduus mammal
as cfined by the Cupertino Municipal Code.Chapter 9.12.and the Health and Safety
Ode,Section 25532m)? All roofs shall be inspected prior to an roofing material beim Installed.
❑Yn Ne P P Y g g
Will the applicant or future building occupant use equipment or devices which If a roof is installed without first obtaining an inspection,I agree to remove
havardous air contaminants n defined by the Bay Area Air Quality Management all new materials for inspection.
riot?
❑Yes VdNu
1 have mad the hmardoas mamrialarequiremenu under Chapter6.95of the Caliper.
.is Health&Safctycode,Sccbon 25N1 533 and 15534.1 understand thatf0l building
does not etmeml a tenant,Ne is my remomibility m notify the cup of the
requimmcros m t rtonumance0aCent teamofo�rcu cy� Signature of Applicant Date
OwncVo uNoriacJ ager / D,m All roof coverings to be Class"B" or better