05060226 I
CITY OF CUPERTINO
BUILDING DIVISION PERMITCON RACTOR IINFORMATION , :
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BUILDING ADDRESS: CAREY CONSTRUCITON ......05060226
.R'S NAME: PERMIT ISSUE DATE
PHONE: SANITARY O. CONTROL NO.
ARCHITECDENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
u0z LICENSED CONTRACTOR'S DECLARATION MIb Description
0 I hereby affirm bat 1 am OI licensed under previsions of Chapter 9(commencing P
with Section 7")ofOTvidon 3.f W Bunco.and Professions Code,and my lice..is
^� in full forte and.frect.
pz Lieen.elaas Lk.g REVISION--ADD SKYLITS (CLOSET)
-- Dab Contractor NO NEW PERMIT ISSUED/ORIG. 405050150
ARCHITECTS DECLARATION
ir MIn records
I uemand my plans"I mad public rords
g
,8t; Licensed professional
OWNER,RURDER DECLARATION
I hereby afore.that 1 am exempt from Ne Convamors License Law for the
O fallowing reason.(Section 7(171.3,Business and Profession Cade:Any city or county
$tri which requires a permit in construct.error.borrow.demolish,fir mPoll any atrueture
prior to its issuume.alsu requires the applicant for such Permit b Ne a signed statement
< rwhalaicensedpuwantbbeprovisions ofd.Conuacbraumn.Law(Chapter 9 Sq.Ft. Floor Area Valuation $0
�S (commencing with Section 7000)of Division 7 often Business aM Professions Cade)or
— bol he 6 exempt therefrom aM the basis fee the alleged exemption.Any violation of
Section 7071.3 by any,applicant for a permit objects He applicant in a civil penally of APN Number Occupancy Type
not mare ban Eve hundred dollars(1300).
01,as owner ofdm property.in my employe,with wages her tiahsole eampeosatim, 37533030 . 00
wlildn the work and be structure Isom intended eralfxed portals(Sao.7644,Business Required Inspections
Nd Profession,Code:The Crewmen License Law Omen not apply b an owner 0I 9 P
prapenywho builds or Irepraws Mooren,and whoda,suchwork innscfar through his
own employme,provided that such improvementa see not Intended wormed ferule.if,
however,be building or improvement Is sold within one year of compledon,the owner.
builder will haw the burden of proving Wt he did not build or improve for purpose of
1.
0 \
Las owner of is(Sec.
.m exclusivelyss and contracting with:)The Cmnuacmrs b
construct La the project(Sec.o an owneBusir
of
and ny who
Cade:)The Cmlr.mrs Lb \
came law da,wt apply a an owner of proprnY wtho builds or imprew Hereon.and,
License ncLL forsach kcu MNaconuacmrtH llonsed punwm Convanora
License Law.
❑lam wemPt an a kPCfor is rtes.. ' I
r /gate
ORKER'S COMPENSATION D ATIO [ J
1 hereby air=under mea ty of perjury aro of He folmwing declarulons:
❑Thaw and wVl malnuiv eCWOwteaf Cansmtmafdnmrefee Workers Campeo-
scion.as provided for by section 7700 of He Leber Code,fee He Performance of the
work for which His permit 4 issued.
❑1 haw and will maintain Workers Compensation Instusaec,as requited by Section
7700 of the Labor Cod.,fee the perfarmenw of be wort for which Hu permit 1.issued.
My Workers Compensation Insurance carrier and Policy number see:
Cartier: Policy No.:
CERTIFICATE OF EKEMP ION FROM WORKERS'
COMPENSATION INSURANCE
Mis secumt need not be completed if He permit is far one hundred dollars($100)
or less)
I sonify,Het In He performance a Ae w k fo which this permit la issue hall nm
employ any peron in say mmn� asi oma subject tiro War ompenuti n ///!
Lawsca Cati(omia.D I `)�i,^/�
Applicant G/ 7
NOTICE TO APP%:VJ aa1 c making this Cemfic.m of Lscm Iron,you Id
th"We subject In,be WorCor.Compcoastion provisions of He Labor Code.you must
,J O forthwith comply with each prevision or this permit shall ondeco ed revoked.
z'y CONSrRUCnON LENDING AGENCY
(~ 1looney Mrom Hx,Hort I..I.dan lending agency for He Performance of
et.> be work for which ora Permit H wand(See.3097.Civ.C.)
Lenders Novo
7 z LandersAddriess
U f7 I certify that I haw reed this applicarlon.d state bat He show information it
{rr come,.I agree to comply with all city and county ordin.ces and ecu laws relating to
O building construction.and hereby authorize representatives of this city to enter upon the
W .hovcmeM...d property for Inspection purposes.
(We)agree to sew,indemnify sed keep bunt be City of Cupertino against
y liabilities,judgments.casts and expenses which may many way. against said City
U 2 m cmuequenem of H gra!or
PW
it.
"" APPLICANT U RSILL COMP Y ALL NON" I I ued by: Date
SOURC A '< lip/
roofs
turn o I UCaDate
HAZERIALS DISCLOSURE pe of Roof
Will the applicant g occumplatme or handle hvudous material
defined by the Cupertiode,Chapter 9.13.and the Health and Safety
a,Section 2337Z(U7 All roofs shall be inspected prior to any roofing material being installed.
❑Yea
V4911 the applicant ne eecuwnt ba equipment art aMma wore. If a roof is installed without first obtaining an inspection,I agree to remove
emit nvardnm aircmuminanu as @lined by the Bay Area Air Quality Management all new materials for inspection.
District?
❑Yes ON.
1 have mW the hasamnmmaterial.equiremenu underCluPter .93of the Califon
nieHmlNA tyC .arm , S7(IS.OSSJJ un123374.1 undcmmn the
building
dos am c ly h a ten.L Hal II b my reWonsibility b nn tiro occupant of He
m hk Prior to In.. run of Occupancy, SI alupeofApplicant Date
sunt nuinomMsgem Date All roof coverings to be Class"B"or better