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CITY OFCUPERTINO^`''
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BUILDING DIVISION PERM*
BUILDING ADDRESS:
CHURCH IN CUPERTINO
PERMIrN 03120042
OWNER'S NAME:
PERMIT ISSUE DATA
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SANITARY 907 1 oL NO.
ARCHITECD'ENGINEER:
BUILDING PERMITINFO
BLDG ELECT PLUMB MECH
LICENSED CONTRACTOR'S DECLARATION
lb Description
o
isioof Chapter 9 (commencing
I hereby alfim that 1 am licensed under pwvm
with Section 70110) of DJ0xion 3 of due Businessand Prefessinm Code,and my license is
In full fora and effect.
Llama Class Liall
ENLARGE CHURCH ASSEMB ELEVATOR &
Dam Contractor
ARCHITECTS DECLARATION
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I undersand my Plans eWi W hand As public axaml,
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Licensed Pwfcssanal
OWNER -BUILDER DECLARATION
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I hereby Affirm that 11. exempt from the Contactors License Law for the
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following reason. 7(D 1.3, BaalMas And UN Any city or county
t cl. alcor. improv, demolish. a repair stractuMMmcni
Permit w,
which Diu basinti a permit to
uim t IMMiLlm W
the inion Law(Chopua t
priorm its mated m law(Ch
Sq. Ft. Floor Area 0 Valuation
p,Ahorequires
IhmhelalinSwi p rwantlODO)of provisions offartachlemtwofileen
and
Nans
oftCBui Cade) of
)or
Solon]0nd of Division3 oftheBedexem dart.
(nd
1
myons
ttewith
that W a eanmpl IWrtfmn and the baalr for due Wrycd exempdan. My violation of
he
Station 7031.5 byarry applicant fan a Permit subjects the applicant to a civic penalty of
APN Number cupancy Type
not mart dun ftw boosted dollars ($500).
i
0 I, As owner of the property, «my employes with wiles As Unit wit ampelwtion,
Q Required Inspections
will do Ne work, and the smcwm isnot Intended ars@ted far ,It (Sec. 70th, Bonn.
sed Pro(eulona Code: The Cantrwmra Llame Law does,not apply a an Om" of
properly who build, or i mprnva theran, and who does such work hlmsel f or through his
own employees, provided thatauch Improvements seat not Intended or offered for We. if.
however, the building or Improwmant Is said within ane year of oompledon, me owner•
Wild= will haw the burden of proving that M did not build or improve for purpose of
Asia.).
1, As awaer of the property, am exclusinly connecting with licensed anu¢wn to
tract the project (Sec. 70414. Business and P efetuom COCA:) The Contrscmr's U.
awe law does not apply m an ower of property who Wit" or hamews duccon, And,
who contracts for such projects with a antrwmr(s) licensed pursuant to the Contractors
License Law.
❑lam e.emp Oer Se .B&PCf .W, on
p,ue..A I[�
WORKERS COMPENSATION DECLA ON
I hereby afRrm ander penally of perjury arc of the following declarstions:
Coent to,elf-moue fa Worker'sCompen-
haw and w0i maintain h CeNOoreofns
salon, as provided far by Sation 3700 of the labor Cade. far me Pont... of dm
work for which this permit is issued.
❑ I haw And will maintain Warkers Compensation Insurance, As required by Section
3700 of the laWr Code. for me perfomwee of that work for which this permit is issued.
My Worker's Compensation Insurance carrier had Policy number am:
Cartier: Policy No.:
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
t
(This section ccs trot W complete( flow Mouth is ferane hundred dollars (SIM)
M lana.)
I anify that in me Wit.... of the work fa which this permit is issued. l Nall not
employ any person in any meaner an As In become subject in the Workers' Co rTmnsation
Laws of Califoma. Data
Applicant
NOTICE TO APPLICANT: If. otter making this Cen10cale of Exemption, you should
become subject to the Workers Compensation provisions of the labor Coda, you mum
faMwith amply with such provisions or this permit.hall W decreed ranked.
CONSTRUCTION LENDING AGENCY
I thereby affirm dual Vert ism com uctinn leading agency for the performance of
the wart far which this permit I. Wood (Sec. 3097. Civ. C.)
leMces Name
Lenders Address
1 ceniry that I have read this application AM some thin the amw information u
comet. I Agra to comply with all city and county oraiaeces and state law mlating to
Wilding commuelion, sed hereby authodre mprasenmiws of this city to Anne upon me
shout -mentioned property for fmpecdon purpa cu.
(We) agree w aw, indemnify And keep hmmlest me City of Cupertino against
liabilities, judgments, costs and espentes which may in my any weave against and City
in cormsegaence of the treating ANNA Perris
APPLICANT UNDERSTANDS AND WI COMPLY WITH A NON POINT
Issued by:S4tQ� Date
SOURCE RR! Ul IO�NS.�t
Re -roofs
Type of Roof
;w1kanotdAppliemUCOmmator `� -r
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future Wilding occupantawte or handle hemdoos material
As defined by the Cupertino Municipal Code, Chapter 9.12. and the Healdu ad Safety
Cods, Section25532()7
All roofs shall be inspected prior to any roofing material being installed.
Oyu )(No
If a roof is installed without first obtaining an inspection, I agree to remove
Will the applicant or future Wilding asupant use equipment or devices which
humirm air cataminaats As dcRecd by the Bay Arta Air Quality Management
all new materials for inspection.
alai
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I haw mad the haanlnus material, requirements under Chapter 6.95 of the Califor•
nia Hcalm dr SafetyCode, Sectors; 755(15.15533 red 25534.1 undersand that lithe Wilding
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data not currently hew a ananh mm It h my responsibility m redly me ,xeupant of Nc
myulm wIt It WWmelpriorwiss oncertinmaarOc n
Signature of Applicant D to
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All roof coverings to be Class "B" or better
wncr ter mthorucd egcnl sat