05040175 CI TY OFCUPERTINO 'p� ° �y.��a.y�a�t'>�^�*!{� '"'�ya!�`` .'`' "���i''
BUILDING DIVISION PERMIT 14CO1'�IPASIAOR NFV��"^f Tl i V R
'fF%�'^ai
BUIL DING ADDRESS: MURPHY TRAM/MY—NGA DO PERMIT NDO 5040175
OWNER'S NAME: FERMIT�UBDATE
E; SANITARY O. C Nkq.NO.
ARCHITECTIENGINEER: BUILDING PERMIT INFO
p PLO t�
estop
LICENSED CONnRACnOR'SDECLARATION Jobb LED
section
i I Manby affirm Net 1 am licensed under providom n(ChaPur 9(commencing
< with Sation 70(lU)of Divialonlof N6Busircuand Pmfeulnro Code,and my license is
< in full forte and rj
z LlcenscCl Lia.{ S DEMO (E) HOUSE
Dem Conuumr �oo�
ARCHITECTS DECLARATION -O
y I understood my plans&hall be used a public record
3 U
.hod Licensed Pm(eainnal BUILDING
U'a ®'B pG
M
OWNER-BUILDER DECLARATION yR L N
a1 thereby.(Sect mat 11. exempt from io Contractors :A nm law for to
o O following meson.(Section IIG LS,common,slow, and vs,,de ons Cade:Any city ar county
$ which mquis a•permit res es,thalar.Improv,daermitt orrepairpair ed almetum
prior mits Wuedpuronrequire theApplicantof for rvchpermerocense Ludantemcm
�F< morMisctril with
pSectio 7 me previsions of thcndBase ra Lkenulaw(Chapter9 Sq.Ft. Floor Area Valuation
3 0 from a is com with Sentil 70nd the
Division 3 of And aged casand Profcnkvi Chic)m
� Net M u eampl thertfrom oad me baa for me Alleged esemption.My violation of
Section 7031.3 by any applicant for a permit subjects tie appikanun a civil penalty of 3 7IFF7040VO0 Occupancy Type
not mart Nan fin hundred dollars ISM
❑I,a owner of the property,or my employees with wages As mebmk compeoution,
will da the work,and to structure Is test intended oraRemA forsale(Sec.7044,Business Required Inspections
and Profs,ssim Cade:The Contributes License &toto Law doet apply an owner of q P
property who buildanrimpronf thereon.and who doeauch workhlmselforthrough his
however,
buiprovided pr such ImPronmmuartns,IouMe4oroReedf Owner.
however,Ne building or improvement is las
ort you of mprokdoa Ne ovmco-
Wilde'
will Mn tite burden of proving Nor M did not build Or Improve for purpose of
tole.).
❑1,as Owner of me property,am exclusively commuting with licensed convectors in
construct the project(Sec.7044,Business and Profusion Code:)The Convanofa Li-
cense Law does not apply On an owner of property who Wilds or Imprints thereon,and
who contracts for such pmjecu with a con owerM licensed pursuam in the Consumes
License Law.
❑1 am exempt under Sec. .B&P C for mix tam
Owner Dam
WORKER'S COMPENSATION DECLARATION
1 hereby affirm under penalty of perjury not of the following decluatimu:
have and will maintain•Cem6eate of Conant to ulf-imam for We row'sCompen-
atian,a provided for M1Y Stttion 3700 of we Mbar Cade,fm the performance of me
work for which cob permit a issued.
❑1 hose and will maintain Workers Compensation Imuran&,AS required by Section
7700 of me Labor Code,for me performance arms,weak for which this permit is Issued
My Workers Compensation Instance rimer and Policy n�u-m-sbe�r toe:
Co.er: � f tO Policy Nit: 1:15 !—; _but
CERTIFICATEOF FTE%EM PITON FROM WORKERS'
COMPENSATION INSURANCE
(Thisuction need not W completed if me permit lafmme hundred dollars(SIM)
Or Lea.)
1 canify that in the performance of the work for which this Permit Is Wood,l Nell not
employ any person in my transition As in become subject in the Workers'Compensation
Laws of Celifamia.Dau
Applicant
NOTICE TO APPLICANT.IL a(mr making Nis CeniBcate of exemption,you mould
become subject in to Worker's Compensation provisions of the Letter Code,you mute
.,O formwith comply with Ruch Previsions or this permit shall be deemed cooked. ..
z y CONSTRUCTION LENDING AGENCY
[-+ Thereby M.mat inert is a communion Leading agency fm the Performma of
pi> the work for which mu permit is issued(Sec.3097,Civ.C:)
W�Q Lindcrs Nuns
Leaders Address
('J Q 1 anlfy that 1 Mn read cola application and sum that me&bon information is
Iy ^ cameos 1 agree m comply with W city and county ordwanaund sate laws relNng u
0 rU^ building mawctlon,and hereby aumarice apmunutins of this city m enter upon me
W move-meadoned pmpeny for Inspection purposes.
(We)agree 10 son,indemnify and kap bmnka me City of Capons.aimless
A Iiabilidea,judgment,costs and expema which may in my way seems &W aid City
V'l is annuquencc of the granting of mu permit
r1- APPLICANT UNDER SAND L COMPLY WITH ALL NON-POINT Issued by: Date
ecULAT of
Re-roofs ol
SignsiturcofAl,plicantiCoffirwor am
HAZARDOUS MATERIALS DISCLOSURE Type of Roof
WIII the April=or future Wilding auctions nom or handle hicanioa mmmnal
as defined by dm Cupertino Municipal Code,Chapter 9.12,and the HcJm and Safety
cwe,-Section n532m)7 yyJ All roofs shall be inspected prior to any roofing material being installed.
ElyG �wm
Will me applicant or future building Occupant use equipment or device which If a roof is installed without first obtaining an inspection,I agree to remove
s ha�doua air conuminanu as defined by the Bay Area Air Quality Management all new materials for inspection.
Imict7
❑Yes OU
I ban mad the haallousm s riaurequiremenu underCMper6.95 of tit Califon
.is Health&Sarety ,sectim&25505.2 3and25534.1undersmndmmifdw Wikling
currently not cnrly h a m t,mat ir' y respomibility in molly the occupant or me
.ma which It be tprio issuance or a Cmificate 0c ry. Signature of Applicant Date
Owncro urhorindagent Data All roof coverings to be Class nBn Or better