05050019 CITY OFCUPERTINO /5 M171 .Try ("jp* ^ (��j♦
BUILDING DIVISION . PERMIT �',CgNTPAQT4QA\�;yW' lfrw`•^'!'�
BUILDING ADDRESS: PERMIT NO.
05050019
OWNER'S NAME: PERMIT ISSUEDATE
E: - SANITARY ftkOL NO.
ARCHTIECrIENOIKEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
300LICENSED CONTRACTOR'S DECLARATION O O O
QF E i Mreby art,.thm 1 am licensed under provWans of Chapter 9(rnmmerein{ lob DCSCrI1�p�a-fy�ls4�ypyp��
w�
with Sesrs,And
Division 3ef me BusitwmW Aoressiam Gode.arb mylicense is rtA, A r®
n' in full faux and eneeL �J v!(A.�I(I�` 6`
$z Ucanse clue Lm.s ADD BATHROOM @ 2ND FL. (N
D'teARCHITECTSc°"DEC SAMLL OFFICE/PLUMBING/AC �/
or DECLARATION
I underma d my plans still bu used u public recards T Z005
]yU V
3 0� Licensed Professional
Ry5 OatIameUILDER mptfroECeContrON BUIL®
4 a I naso ,spm on I am,Bump,from tl r Contractors License Law for the
i p o following moon.(Section 711JId,Business and Rofesaium Cam:Any city or county
which requires a permit m construct,alter,Mprow,demolish.or repair any ttmcmre
_ ING
z: prior m its issuance,also requires me applicant for such permit mole a signed statement
R�G that be u licensed pursuant to the provildow of the Consommes Uccme Law(Chapter 9 Sq.Ft.Floor Area Valltatl 000
a (commencing with Srotion 7")of Division 3 of the Business and Profession,Code)or Y1L
g i;$§ that he is exempt therefrom and me bub For six alleged eaempdon.Any violation of
SeWon 7031.5 by any applicant for a permit subjects the applicant In a civil penalty of APN Number Occupancy Type
not more Nan fin hundred dollars,($500).
O L a owner of the property,or my employees with wages a them sole compensation, 36204025 . 00
will do the wok,and the structure is not Intended or offered for Bit(SM.7044,Business
and Professional Cade:The Contracmes License Law cars not apply 0 an o'w'ner of Required Inspections
Property who builds or im prows thereon.and who dons s uch work himsel f or through his
ave"employees.provided that such Improvements tie not intender oroBeree ferule.If,
however,the building or improvement is sold within one year of completion,the owner•
builder will haw the burden of proving that he did not build or improve Tor purpose of
am.).
❑1,as owner of me property am exclusively contracting with licensed contractor to
construct the project(Sec.7044.Business and Pro(esaians Code:)The ContrsemYn U.
came Law does not apply to an owner of property who builds or Improves memon,and
who contracts for such pmjema with a eontractorO licensed formation to the Conuactoes
License Law.
§'I am exempt under Sec. .B&P C for this moon
Owner Dam 'I 3
WORKER'S CO 5 E SATION DECLARATION
I hereby affirm under penalty a perjury oro a(me following declantlom:
/7'3110
haeme will maintain a CeWacam or Camcnt m self4mom(or Waf esCompen-
n,u provided for by Section 37011 of the labor Code,for the performance of me
k for which Nis permit Is,Issued.
have and will maintain WorkeYs Comperwtion Ivurance,u required by Section
of me Labor Code.for the performance of me work fm which this permit is issued.
wades Compensation Insurance eerier and Poliry number am:
ier: Policy Na.:
CERTIFICATE OF EXEMPTION FROM WORKERS' '
COMPENSATION INSURANCE
Mala sextan need nor becompmuml ifthe permit U for.hundreddellan(SIM)
or less.)
1 certify mat in the performance of the work for which this permit is issued.l shall not
employ anyperso"in any manmrse u m.Ilcyorpe suhkn m the Wokers'Compcwdon
Iawsof Califrch.Da ''SS �Z1IG ane
da.,
NOTICE TO APPLICANT.If.alcor ng this Ceniacate of Exemption,you sbuum
become subject m me Worker's Compensation pawlsom of me Lahor Cade,you most '
.J O forthwith comply with such provisiam or thin permit shall W dcemed reeked.
z"' CONSTRUCTION LENDING AGENCY
[-t Thor which
barft.macouSeWnn7,Ch,agency for me performance of
aE the for whichrob permi,binced(Sec.JW7,Civ.C.)
aQ lender's Name
=z Lender's Address
U O 1 certify that I have read this application and sum that the show Information b
enrrcaa 1 agrx to comply with all city and county ordinances and sum has relating to
SV' building construction,and hereby mmoin represenudws of this city m enter upon me
4TI throve-mentioned property for Inspection purposes
(We)agree m taw,indemnify and keep harmless de City of Cupertino against
M liabilities.judgments,ants and expenses which may in any ray amus again,told City
V 7 In consequence or me granOng of this permu.
t� APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT Issued by: Date
SOUR SREGULA"In
--_1
Signuurea(AppUonVC 7yof tam ata Re-roofs
HAUROWS MATERIALS DISCLOSURE Type of Roof ,
Will the applicant or future building occupant more or handle luxurious mamdal
as cleared by the Cupertino Municipal Cure.Chapter 9.12,and me Health and Safety
,sacede.Scotian 2ss3z(a)7
Yes u All roofs shall be inspected prior to any roofing material being installed.
❑
WI11 dm applicant or imam banding occupant use equipment or devices winch .If a roof is installed without first obtaining an inspection,I agree to remove
R box dam it conmmimnts a donned by the Bay Area AI,Quality Management all new materials for inspection.
uricti
❑Yes u
I have mW the huarmms materials requirements under Chapter 6.95 of the Calller-
meHealth&Safety Cade,SeNam 2.55)5,23333 and 25534.1 mumminnd that if tie building
dam not curcntly hove a tenan4 me,It h my responsibility m notify We mupant of me
requimmcnm which must be m pdormiuuareeolncerunesmoroccupmcy' Signature of Applicant Date
fn r' �''l°� All roof coverings to be Class"B"or better
Owner or authorized IS Dam