04030159 CITY OF CUPERTINO '�>
BUILDING DIVISION PERMIT CONTIU&OR INFORMATIO
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BUaDING ADDRESS: ANDERSON INSTALLATION PERMIT NO.04030159
OWNER'S NAME: PERMITLSUEDATE
II
E: SANITARY OL NO.
ARCHITECT/ENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
0 0 0 0
+�s00 LICENSED CONTRACTOR'S DECLARATION - Job Description
F 1 krchy.(Vero that I am licensed under provisiou of Chapter 9(m humming p
n� wlmllto=a deffe Diviaian Sof the Business and Profculuu Code.and mylicenw is
„ in m0 roam and ercect
Z
LkenmCleu oWINDOW UPGRADE
Cndo
wF Date Cod Ispu
wtor
ARCHITECTS DECLARATION
�i 1 understand my plans shall he used u public mcnNs /
3 Licensed Professional
OatNEm attempt
[r DECLARATION f/�/
0 0Cis
1 hcmhy.(Item nd 1 a1.uusin from d a Comnetah License c taw for the g7G
i p O fallowing mmoa(Suwon]onstr,Bulinus and ae,donna Cade:Any tiny Or county
+�$ which)italics a permit ra mnswe4 eltee nt reeve,demolish,of repair ed stmnute
F < prior m IB issuance,aimpursuant
n to the the applicant rairsuchthe Can Monis toles a Law
ststemcm
O (hat Com eslocal withSection7 h)previsionss hapter 9 Sq.Ft. Floor Area Valuate
$ (cat he Isngwith Senior]0110)of basis for
the
thea ed esomplmsAnvi Cook)or
.. Natio m 31.5 b therefrom and the per for the subjects
due exemption.Any it Penalty of
Section pan five
any applicant for a permit cabJecss Ne applicant to a civil penalty of 7YP
non mum man Rw hundma dolma($500). 3�i�(�9RT�I O O Occupancye
❑I,uownerofthepmpcny,wmyemploycuwithwagesumeirmkcompenunion,
will do the work end the tuactun ignminmaded orolkrtd forenle(Sec.7044,Business
and Profession Code,The Cannot License Law tars not apply in an owner of Required Inspections
propenywho builds or improves themon,endwho doeseuh wohhimtelf orduough his
own employees,provided Nan cash impmwmenu art non Intended mortared Wash.U,
however,the building or improvement is said within oro year of mmplin on,the owner.
builder will have the notation of proving Wt he did not Wild or improve for purpose of
ulo),
as ownu of she propeny am excludvely conuseting with licensed commission;no
'co tract the project(Sec.70th,Business and Profusion Code:)The Contractor's Ui
cave law does not apply to an owner of Property who builds or Improved shemon,and
who contracts for such pmjem with amnu icuu(s)licensed punuann to the Conerecwr's
License Taw.
❑I am uempn under See. B&P C jo,flus B moon
wncr —�— 3 ? 4'
WORKE 1P• A •C
1 hereby&Man under penalty of perjury ow of dta toll wing declaradonss
1 have an l will maintain aCenffimte ofconsent to wl6insum forworkeescompen-
utlon,as provided for by Section 3700 of the Labor Code,for the performawe of his
work for which this permit is issued.
❑1 have and will maintain Worker's Compensation Iumance,as rtquirtt by Section
3700 of me labor Cade,for dm performance of the wods for which this peanir is isstmd.
My War Conformation 1.urtica and Paltry number art:
CaMcr. Policy No.:
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
frTb=arm wed notnscompleted if the permit Is foram hundred sullen($10(d)
or ksa)
1 unify than in We perfmmmed of the work for which mice permin B issued.l shall not
employ any person in any mannerm as on become subject to be Workeni'Compenandon
Laws of California.Data
Applicant
NOTICE TO APPLICANT:If.after making this Cenificam of Exemption,you should
become cabjmt to the Workers Compensation previsions of the labor Code.you must
.J z foMwith comply with such provisiou or this Permit Mall be doomed=a"
z` CONSTRUCTION LENDING AGENCY
i" I hereby alarm mu them u a comuucdon lending agency rn)the performance of
C dta work for which this Permit is issued(S..3097.Co.C.)
Q Lender's Name
a7 z lender's Address
t.1 Q 1 certify that 1 have lead this application cad sum tou the above Information is
F coned I agree to comply with all city and county muinauv and saw levo totaling in
QU building convection,and hereby eumorim mpruenutives ofilds city no enter upon be
W above-mentioned property for impaction purposes.
(~6. (We,)egme to caw.indemnify and keep harmless dm City or Cupertino against
Nl IIa1h1110c.,Judgments,costs and expenses which may In any way seem against mid City
in cmosequewe of the granting of this permit.
C7 APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT Issued by: do Date
SOURCE GULATIONS.
3 h oy Re-roofs
gnawrt ofApplie HAZARDOUS MATERIALS DISCLOSURE roo(Con tor a4 Type of Roof
Will me applicant or forum building Occupant sort orlarrom huallous mammal
u&Rued by she Cupertino Municipal Code.Charm,9.12.and me Health and Safety
rade.Section 2ss32(.)? All roofs shall be inspected prior to any roofing material being installed.
❑Yu No
Will
the. Beane or mom bwmm Occupant n If a roof is installed without first obtaining an inspection,I agree to remove
pp g p equipment or devices which g
..it hoeafdou air cia mrmints as;de0ncd by the gay Arta Ail Quality Management all new materials for inspection.
District?
(:3 Y. Nu
I have mad me hmndous materials mquimments under Chrpoe 695of me Califor-
niaHcalth t SafcdyCodo,Smtion25505,25533 and25534,I undcmmnd mel if the building
docs not currently hum a tenant that it is my responsibility to mull the occurred of the
mgairetswni red men pd issman ofaccnlneamoro"it c. Signature of Applicant Date
3 17 ON
Owner or audhodus agent ata I All roof coverings to be Class "B"or better