08030175 CITY OF CUPERTINO -
BUILDING DIVISION PERMIT ,CONCY2A�'F'QIi�IN'FRRMr�'TION -�-
u f,�.v, °'�� � k.•�•�r E#h •y,x :•N?$�a R, 5<Kv�".udh €�+ I+q,
9uI1.D11YO�ppBESS:ALO VISTA RD TBD — TO BE DETERMINED PURCOSU175
NE1R'US NA�MEU: Y PERMIT ISSUE DATE
04/01/2008
PHONE: SANITARY NO. CONTROL NO,
ARCH=tENGINEER: BUILDING PERMIT INFO
BLDG EIFCI PLUMB MECH
Sop LICENSED CONTRACTORS DECLARATION IOM DDSCrI VOP
U 1 Wreby affirm that I w licensed under previsions of Chapw 9(commencing
wiNSection7")oft) tion3of NeBWnmud ProfcWou Cadm,a mylicenwis REV, REDUCE 6" IN BLDG WIDT , ORIG #08020150
u in fall farce and effect
55aZ License Class Lm.g
y, Dam Contractor
q - ARCHITECT'S DECLARATION -
2 1 undersand my plans tall M hand u public records
50 Licensed Profesvonal
y OWNER-BUILDER m DECLARATION
ON
COO bereby ahem on 1 am exempt from Ne far aactooa License city
o for the
COO o following retro..(Section 10013,t.alecu and PrafdWons Cade:Any city or county
w which inquires a Permit re consort,alms.wfor such
hPerdemolish,ri sepsis any swctum
Sly
prior mits censed slach=altorequiresft lhovisios of for ewhpermitm0leasigma.ummcnl
p Nu k u licensed Pamunt m We provisions of the Contractor's license law(Chapin 9 3q.Ft. Floor Area $160 Valuation
y 3 (commencing with Section 7000)of Division 3 of Ne Business and Premaacans Code)or
`; dm he is exempt therefrom and the balls for the Weed exempt an.Any rWmian of
Section 7031.5 by any applicant far.permit subjects the applicant in a mil Malty of 3 57 02 0 51��Number Occupancy Type
not fame Nen fine hundred Mists ISM
1,u owner of Ne propeny,m my eaploymes with cages u thetr sole compcwdw,
Wild da Nn sits.Yin Ne he Comandes License
.taw don, a apply.70N,BYGKof Required Inspections
and ROfesaions Cade The Contacmn,and
who law does not apply lf rt owacr of q p
hadaproperty who wilds ti ed that
such unpr and who dwsawh work himeelforNreuah his
hownw.lthen,pin gorhlutswhimprowmeatsue not ear of araffetoiln.far sale.If. -
boileler the Wilding or MProwmmrttssaid withinoreyear ofcoartsfarNcowner-
wildu vi0 Mw the btuda of poving that be did not wild or Imports far purpose of
trial.
❑1,as Owner of the property.am exclusively contracting with llansed con ocaus to -
ocarm ct the project(Sec.7044,Business and PmfeWou Code:)The Conuactata U. t
«sae law does not apply to an owner of property who Milds or improws Noreen.and.
who contracts for such projects with a conlranar(s)licensed pursuant to the Contractor's
License Lw.
❑I am caempt under Sec �A,��P C for this reason
nu // Data
RK 'S COM ENS ON DECLARATION
1 hereby aBirre under penalty of perjury ane of the following decimations:
❑T hem and will far by Section
3100 of the Labor
Code.for We Workman ce of the
Won.as provided(pe mi Section 3700 a(the Lahr Code.far Na performance of the
wank far which Nis permit is iuwi
❑I have and will maintain Workeas CompevNon Inman¢,u requimd by Seedan
3700.f the Labor Code.far Ne pesformanceof Ne work for which this permit is Issued. '
My Workeas Comperamian Insurance carrier and Policy number art:
Cartier: Policy No.:
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(Thlametion wed not becomple m!if the Permit is Intern hundred dcalisa(S100)
or mu)
I certify Not in the performance of the work for which this Permit Is Vuwd.I shall not
employ any Mean in any
Applicw /manw740
are
iftwo rr Compensadon�/Lawsof CaiifamiaQ . � �
_
NOTICE TO AP� Certificate of Exemption,you should
become uhject in the Worker'.Compensation previsions of the Labor Codc,you most
vJ O forthwith comply with such previsions w Nu permit.hall he deemed mvoked.
,z,� '-"
CONSTRUCTION LENDING AGENCY
(tiff Ihemby affirm NU Nem I..construction leninpgency,far tM performmce u(
a> the wish far which this permit Is Wood(Sec.D)W.Civ.C.)
Q Landba's Name
.7 z
Latrines Address
U Q I certify that I ham tad this application and sum Nu the.how information I. -
LL F coizet.I agree in comply with all city and county ordinances and sum law misting in
Q V building construction,and hereby anthorim rept enutiva of this city to color upon the
t37 show-mentioned property for impaction purposes.
(We)agree to save,indemnify and keep harmless the City of Cupertino spire,
Vl IfaMlifies,judgments,casts andaMmes which may in any my cc=against said City
(„)Z in covegwnee of Ne granting of this permit.
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT Issued by: Date `7
SOURCE REGULATIONS.
Signuurt am Re-roofs
HAZARDOUS MATERIALS DISCLOSURE Type of Roof
Will the appliant or future building occupant atom cathartic haurdous material
as defined by the Cupertino Mumdpal Code.Chapter 9.13.and the Health and Safety
Section I5532(a)7 All roofs shall be inspected prior to any roofing material being installed.
❑Yes VJNo
Will the.firlicant or future wilding aaspam use egmpmat or dears,which If a roof is installed without first obtaining an inspection,I agree to remove
emit husmout air contsminants at defined by the Bay Ams Air Quality Management all new materials for inspection.
District?
❑res 0.
1 hew rad tla haardons maedau mquimmcnu.adc chePmr 6.95 ofd.Califor.
nu H.Ol &SafdyCadc,Section 15546.75533 amM534.1unM1rsvm thsifNc Wilding
does Out currently haw a count this it u my responsibility to entry Ne ampam of the
manpiormisum ofaCwf�morormtrP.Z Signature of Applicant Date
° f ad
Owner or authonycd agent All roof coverings to be Class')"or better
Dau