04110023 (2)4
CITY OF CUPERTINO
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BUILDING DrvlsloN PERMIT
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BUILDING ADDRESS:
PERMIT NO.
04110023
OWNER AM ;
PERMOUSUBDATE
3 2
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SANITARY OL NO. --
ARCHITELTIENGINEER:
BUILDING' PERMITINFO
BLDG ELECT PLUMB MECH
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LICENSED CONTRACTORS DECLARATION
Job Description -.
1 thereby afnrm that 1 ane Ilansca under provisions of Chapter 9 (ammeneing--
with Secti 7IXIU)uf Division 3af the BuYPegsnd PmfeWom Coder. and myliceve it
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ia fail
an r and erfmt_ l a so 3
Dam DD—co`
WATER HEATER/ELECT.�'DRYWALL GARAGE
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CONTRACTOR: NOR -CAL CONTRACTORS
ARCHIECISD ATION
d�du sound my ph ...hall be used u public rtcaraf
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Licensed Professional
OWNER -exempt [r DECLARATION
Conan er License law for the
I hereby .(tion cin I em exempt Iron the COntrns
and tau Case: MY city ar aunty
moon. (Saito R13L6. Co my
. after.
which acquires Improve.
which mqussm • permit re alter, hnprove, demuhah, a repair ed
tires he
comment print mitalsmance,rsu ngoins led applicant forsoch Contra loilbfiense Law (Chapter
is licensed pursuant toe) or the camncmr'and
Sq. Ft. Floor Area
VahL1i{0[1000 -
Prselaw(chapter9
(that commencing of Division then Business and Cable) of
(amnmemmngwith Section 7”) D
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alis f r dass on. My
But he a eaemPt thertfrom and Ue basis for the alleged exantpeon. MY violation of
the
Section 7031.5 by any applicant far a permit subjects the applicant in a civil penalty of
APN Number
Occupancy Type
ml mom Nan fivehuedrtd do1Ws (U00),
❑I.sat ovemrofwaProperty. «myemployeesawith wateoatheir Wecampanaaemr,
36909004.00
Required Inspections
willdoth ouskandthestrumuab not intended or offered lunatic (Sec. 7044. Business
and Profession Case The Conmctah LlaaRa Law does net apply to an owner of
property who builds orimproves Nenon, and whoduusuch work himselfor through his
,
own employes, provided that such improvements am an, intended nrafferea for We. If,
however, the building or improvement is mM within am year of completion, the owner-
builds will have the burden Of proving that he did nor bald or improve hor purpose of
.
ale.).
❑ 1, as owner of the property, am exclusively contracting with licensed conuamon an
construct the project (Sec. 7044. Business and Profession, Code:) The Conaanmfs LL
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come Law data not apply in an owner of property who builds m improves etaen. and.
.
who convects to, project Wth scum memr(t) licensed pursuant in me Cona ernes
License I.
❑ I am tempt under Sec. ,B&P C for this runts
Owner Dan
WORKER'S COMPENSATION DECLARATION
1 hereby afflm under penally of perjury am of the following dethumdou:
have and will maintains Centificartraf Conran to self4uun for Warker'sCompen-
Raeon, Raprovided for by Section 3700 of the Labor Code, for Ne performance or the
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work for which this permit is issued.
1 have and will maintain Worker's Compensation luunna, u required by Section
3]00 of the labor Cone, for the perfomma of the work for which this pemit is Issued.
My Workeh Compcnantian Inannna caroler aha Pollry no bar are:
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Ca ' �IAIJ' i QQ
CEK n171CATEOF EKEMPno W RK S'
COMPENSATIO URANCE
(This section need notbecompleted lrthe Permit Is foram, hundred dollars (SIW)
or lets)
1 certify that in the pealam. of m , work for which this permit is issued. I shall nor
employ any penoa in my manner an as in became subject to the Wolkem' L'ompensadon
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Lava of California. Dam
Applicant
NOTICE TO APPLICANT: If, after making this certificate of Exemption, you Amid
become Subject to the Wokera Compensation provision or the labor, Code. you most
forthwith comply with such Provisions or this permit hall be deemed Doled.
CONSTRUCTION LENDING AGENCY
1 hereby alfim that fere b• couaucdnn lending.re fm ft per(omameof
the work I. which this permit B Issued (Sec. 309], Civ, C.)
LendcrS Name
Lender's Address
I avtify that I have read this applimakut and sante that the above WormNun I.
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armor. l agree in comply with all city and county ordinances and sou laws relating to
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building contraction. and hereby authoda representatives of this city to enter upon the
above-mentioned property for inspection purposes
(We) agree to Rave, indemnify and kecp hamlesl tit City of Cupertino ROW
Iiabiliea,judgmemis, eotu andexpensu which may in any way amus against Wa City
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In consequence of the granting of this permit.
APPLICANT UN ERSTANDS AND WILL COMPLY WITH ALL NON -POINT
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Issued by: Date
SOURge RE TONS, n
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Re -roofs
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Type of Roof
Sig¢enTn of Applicant/Comosmr Data
HAZARDOUS MATERIALS DISCLOSURE
Will the applicermor from bdldlng occep samem orhandle huallous mamrW
as defined by the Cupertino Municipal Cade, Chapter 9.12. and the Health and safety
Code. Section 25532(x)?
All roofs shall be inspected prior to any roofing material being installed.
C] you No
mum Wilding
If a roof is installed without first obtaining an inspection, I agree to remove
Will the applicant alOccupant use equlpmem or devices which
It husrdous air eommum nus as defined by the Bay Arta Air Quality Management
all new materials for inspection.
iwsO
❑Yes u
I have mal the har materials requirements under Chapter6.95 Ofthe Cslifor.
nla Health & Safely Cana, Seceons25505,25533 and 25534, I understand thmifet Wilding
does not curmndy have • snot. that It u my responsibility to unity t occupant of me
Main mawhich m be at .to ar.cwncateafGatrpatey.
Signature of Applicant Date
All roof coverings to be Class "B" or better
Owne
r or ayad seem Dan