03120058CITY OF CUPERTINO
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BUILDING DIVISION PERMIT
EUR DING ADDRESS:
PERMIT NO.
03120058
OWNER'S NAME:
PERMIT ISSUE DATE
JIM ANN
E:
SANITARY OL NO.
ARCHITECTIENGINEER:
BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
LICENSED CONTRACTOR'S DECLARATION
Job Description
1 bemby affirm that 1 am Iiceucd under provLaions of Cbapmr 9 (commencing
p
with5.tian 70lllq of Division 3 of the Quainas and Professions Code. and my license is
Liemfull fomeantl effect � 6 T
Cress �T
FRONT DOOR/TRASCOM & ELECT ��sa
INALIED
Gold Coal
Dam c°nDEC
•
CONTRACTOR: PRO BUILT
ARCHITECTS DECLARATION
I undersunJ my phu shall M seed as public rt.ms
x a
DEC 2 2 2003
Licensed Professional
OWNER -BUILDER DECLARATION
I hcrchy affirm that I am exempt from the ContractaYs License Law for the
following mamn. (Section 7031.5, Business and Professions Code: Any city or county
BUILDING
which requires a permit to conWine, mt, Improve, cornetist, or repair any structure
prior to us issuance, also requires the appliant for such permit t° rite a signed statement
Sq. Ft. Floor Area
Valuation
that he is licensed pursuant m the provisions of the Comracter's Licence law (Charm, 9
(commencing with Section 7000) of Division 3 of the Business and Professions Cade) or
that he Is exempt therefrom and the bake for the alleged exemption. Any viola0on of
no
APN Number
Occupancy Type
Section 70315 by my applicant for a permit subjects the application 0 a civil penalty of
not mom than Bw hundred dollars ($500).
❑ 1, as; owneroftht property.myemplcy°u with wagussJmBmle Compensation,
6 ' 0 0 Required Inspections
willdo tha"&-and NesUucmm is notimm�ded woBemd forsake (See.7044, Bur^...
and Professions Code: The Comnctorl Liceue Law dace Out apply m an owner of
property who builds en i mprovse thereon, a rad who does truth work h(me d f or through his
ownemployccs. provided that such improvements are not intended croRered formic. If,
lonesome. the building or improvement is sold within one year of compiedon, the owner
builder will have Eta human of proving Nat he did not build or improve for purpose of
ale.).
❑ 1, u owner of the propeny, am asecluively contracting with licensed contractors m
Construct the project (Sec. 7144, Business and Profusions Code:) The Contrect.'s Li-
cense law does not apply m an owner of property who builds or improves thereon, and
w contracts for such projects a conuaemr(s)/licensed purmam in the Comeact.S
/with
rax Lew. Z
Nps )//R'laC!
-
trmezemptunderSem - B&I'Cforthismuon
Owner Dam
WORKER'S COMPENSATION DECLARATION E,
1 hereby affirm under penalty of perjury ane of the following declarmans:
1 hew and will mainmin a CeNfiate of Consent to self insure fu Worker's Compen-
smon, as provided for by Section 37W of the labor Code. for the performance of the
work for which this permit is issued.
❑ 1 have and will maintain Workces Compensation Insurscc, as required by Section
37W of the labor Cade, f. the Performance of the work for which this permit Is issued.
My Workers Compensation Insurance carrier and Policy number art:
Cartier. Policy No.:
CERTIFICATE OF EXEMPTION FROM WORKERS'
_ COMPENSATION INSURANCE
(This section need not w complemd lithe Permit is Intone hundred dollars ($100)
or las.)
1 certify, Nat in the performance of the work for wh' is permit ke issued, l shall not
empl°yanypersTB ly/nym Bran wbec° JMelker s
laws of alit am
Applic
NOTIC APPLICA ; 1 , e r makmg NI c i0 tl mpti , ou obTa
become subject to the Worker's Compensation provisions of the laver Coda you must
forthwith amply with such provisions or this permit shall he deemed revoked.
CONSTRUCTION LENDING AGENCY
I hereby soft. the, them is a Construction lending agency far the performance of
Ne work far which this Permit Is issued (Sec. 397, Civ. C.)
lender's Name
- f.>
lender'sAddress
1 certify that 1 have mad this application and sum that the shove information is
contact 1 agree to comply with all city and county ordinances and sum laws minding in
building construction, and hereby autharia, representatives of this city to enter upon the
awes -mentioned property for inspection requests.
(We) agree to save, indemnify and keep harmless the City of Cupertino against
liabilities, judgments, costs and expenses which may in my way same against mid City
in consequence of the Stoning of this permit.
PPLUNDERSTANDSIAN WITH ALL NON -POINT
Issued by: Dale -
'C WCC
SOURC EGULA,'p'�,�`
Re -roofs
r�\�'�//J f�..�q
it 1 —17S;i I" !
t ApplianUConeracuoDam
HAZARDOUS MATERIALS DISCLOSUR
Type of Roof
Will the applicant or future building occupant store or handle hazardous material
us defined by the Cupertino Municipal Code. Chapter 9.12, and the Health and Safety
Code, Section 25532(.)? `„
All roofs shall be inspected prior to any roofing material being installed.
0 Yes cl ff
If a roof is installed without first obtaining an inspection, I agree to remove
Will the applicant or future wilding Occupant etre egmrmeat or devices which
I, haumnus a1, c.ruminanu as ueE the Bay Area Air Quality Management
all new materials for inspection.
DiaVien
❑ Ye: a
1 have mad the bmamous mamterials poremo nu under Charm, 6.95 of the Caiifor-
_Hcaith&SafetyCodc. Sections 25505.25533 and 25534.1 understand that lithe building
doss not currently haw a tenant Nat it is my maponsibility en ratify the ...pant of the
requirements ichmustbcmdpdormiuu a a mramof panty.
Signature of Applicant Date
n
All roof coverings to be Class "B" or better
Go,
r authorized agent