04030204CITY OF CUPERTINO
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BUILDING DIVISIONPER MIT
01dll'�
PERMIT N0.
BUILDING ADDRESS:
04030204'
ER'S NAME:
PERMIT ISSUE DATE
N
SANITARY OL NO.
PHONE:
ARCHITECT/ENGINEER:
BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
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LICENSED CONTRACTOR'S DECLARATION
JOU Description
hereby alarm that 1 em licensed under provisions of Chapter 9 (commencing
with Section) )afDivialon 3af the Businesaend Pr°fcu%'una Code. and. IcenY 19
in full Tum effen. ? Lic f}� Cj ��%
License e
const
ADD 492 SQ. FT.
ate'
CONTRACTOR: THREE STAR
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I undcnund my.�le ah ublu mcmda
r
JAN h 2005
Licensed Pmfesi I
OWNER-BUILDER DECLARATION
for
1 hereby of ton that 1 em commit fort the Contractor's License Lew the
following mason. (Section NO I.S. Business and Professions Cafe: Any city or county
which requires a permit to convect, eller, impmve, demolish, lir .,.is any An.fi re
! poor to i%issuance, also leguirts the applicant for such permit w file a signed sukmen(
Sq. Ft. Floor Area�
`�} '732
i rhesheisliccnmdpursuanttotheprevisionsoftheContrator'sldcenselew(Chapter9
ds and Profoaions Calc) or
(commencing wish Section 7000) of Division 3O the Banes
_
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I Net he is eampl therefrom and me bats for the alleged uemptlon. Any violation of
APN Number Occupancy hype
Section 7031.5 by any applicant for a Permit subjects she applicant se a civil penalty of
not mom than Eve handled kilhn ($500).
❑ 1, as omm athe preperty, m or moployeal wag. u thck rule cempenudo..
37505036.00
aired Inspections
will do BR work, end BteaWCWR I.Oet intended or offered for sale 7044. BusinessRe
and Professions Code: The Courec m's License Law Boca not apply to an owner of
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property who builds of improves thereon, and who does such work himself or through his
own employees, provided that such improvements are not intended or offered for sale. If,
however. Ne building or impsevemant is sold within one year of compl°don. me owned
builder will have the burden of poising that be did not build Or improve for purpose of
sale.).
1. as scent of the property. am exclusivelycontracting with licensed conVOe.R to
construct me project (Sec.7044, Busine. end Protestors Code:) The Contractors Li.
cense law does not apply to an owner of property who builds or improves themen, and
who contracts for such projects with a contractor(s) licensed pursuant o the Convector
Licence Law.
❑IamexemptunderSec ,B&P C fm thB lesson
-
arDECLARDate
ATI
WORKER'S COMPENSON ATION
1 hereby afRmt under penalty of perjury one of the following declaratlo n:
❑ 1 Was and will maintain a Ceniftcne of Consent to alf-ieum far Wmycr Compen-
uuon, as provided for by Section 3700 of the Labor Code, for the performance of the
work for which this permit is issued.
❑ I have and will maintain Workers Comperuaunn Insurance.. required by Section
3700 of the labor Code, for me performance of me work for which this permit Is tau L
My Warkera Cramp nsatimn 1 mouse carrier end Policy numbs
artL tK ,� Poliry 2O
uRTIFh ATEOF EXEMPTION FRO WOR ERS'
COMPENSATION INSURA�GE
(This action sed not be com plm od if the permit is for ane hundred doll art ($100)
or less.)
1 certify met in the performance of the work for which leis permit is issued. I shall not
employ any person in any mannish m to become subject to Compematlon
Laws of California. Date
Applicant
NOTICE TO APPLICANT: If, after making this Certificate of Exemption. you should
become subject to me Worker's Compensation provisions of me labor Code, you must
[ forthwith comply with such provisions or mus permit shall he deemed revoked.
CONSTRUCTION LENDING AGENCY
1 herby thi len mem I. lending agency for the performance of
which s ed (See 0
the work for which Nis permit is issued (5., J097, Civ. C.)
Lender's Name
'
Lenders Address
�
1 certify Net 1 haw read this application and men mel the show information is
correct. I agree to comply with all city and county ordinances and mem laws o lacing b
building convection, and hereby aumoria .poe entaincs of this city to ante upon me
for impaction
above-mentioned riotously purposes.
(We) agree to ave, indemnify and keep harmless me City of Cupertino against
r4j liabilities. judgments. costs and expmrse which may in any way see= against aid City
in consequence of the granting of this permit.
APPLICANT UNDERSTAN S AND WILL COMPLY WITH ALL NON-POINT
Issued by: Date
S�I�RCE RECULATIOJJS4��
�.�Q�
Re-roofs
'
Type of Roof
e
�ngnnature of Appl'an ontralm rude
HAZARDOUSMATERIALSDISCLOSURE
Will me applicant or Boom building occupanetote or handle Incautious mistrial
u defined by the Cupeninu Municipal Code, Chapter 9.12. and the Health and Safety
e, &Conn 2553x60"
All roofs shall be inspected prior to any roofing material being installed.
❑Yes 0N
If a roof is installed without first obtaining an inspection, I agree to remove
Will the applicant or future building occupant use equipment or devices which
emit humidities air contaminants a dmfined by the Bay Ar. Air Quality Management
all new materials for inspection.
Dislricl7
❑Yet �No
I have mad the harardousmamrialsrcquimmerm under Chapter6.95 of the Califor.
ria Hca"& Safety Code, Sections Z5505,25533 md25534. I undemund LOOK the building
docs not currently have sena. for it is my mspomihilby in out me occupant of me
reyviremcnts which mu bent promoiauanccofa Ccnifma¢of Oc pry.
Signature of Applicant Date
y 3 e
All roof coverings to be Class nB„ or better
1
or amhc ` d e cot me
cr daTem