05030206 CITY OF CUPERTINO
BUILDING DIVISION PERMITa CONTRACTORAWORMATION <
BUILDING ADDRESS:: PERMIT NO.05030206 S(]3(]Z(]E
749r VROSPECT RD
OWNER'S NAME: PERMIT ISSUE DATE
E: SANITARY NO. CONTROL NO,
ARCHITECT/ENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
0 (� (I
u0a LICENSEDCONTRACTOR'S
unclerSDF-CLARATION ,lob Description
1
e u F 1 hereion? )iitm that I am licensed Bu imas previsions of Coil r 9(commencingsis P
TZ with Section rmaitomcDivision Sof the Bmsiwsand Professions Code.and my license is I
^nd micro laaodeBen. RETROFIT FOUNDATION . UNDER (E) HOUSE i
j�_ Lieena Clans Lk.a
1-,o Date Con DECL
ARCNIZECr$DECLAc mcord -
Jw .m..lmindcrstanJmyplansshall hcused mpublicrccnrds 716/05 CORRECTED FEES—GUST BROUGHT IN CONTRACT
n
a 0 Licensed Pndcssional '
5 - OWNER-BUILDER DECLARATION
<y I herehy affirm that 1 am exempt from the Contractor's License Law for the
no following reason.(Section 7(A 1.5,Business and Ptofassiotu Code:Any city or county
<m� which requires a permit to cnvwct,alter,improva,demolish,or repair any structure
LZi prior in is issuance.also requires the applicant for such permit to Glc a signed gateman
Esu` that be is licensed pursuant to Nc uninsionsnr the Conwcmr'e U..Law(Chains,9 - Sq.Ft. Floor Area Valuation
(commencing with Sermon 7000)or Division 3 of the Business and Professions Code)or $31000
�
i 3$ that he u exempt therefrm and the basis for the alleged exemption.Any violation of $3 10 0 0
Section 7031.5 by airy applicant for a permit subjects the applicant to a civil penalty Of. APN Number Occupancy Type
not more than five hundred dollars($sao). P Y yP
.. t
❑L as own"of Ne Property,or my employees with wages as their sole compenat
WIII dO NC we&.and Ne sWCWre lsn"Intended orOBCRd forsale(SCC.]B64,Bua; s
and Prfessions Cade:The Convector's License Law it=not apply m an owner of U U Required Inspections
Property who builds or i m proses thereon,and who docs such work himself or thmagh his
own emplmyces.provided Nat such impoevomens are not intended aro@ted forage.If, Il till
hmwevar.the building or impmvement is sold within am year of compleumn,Ne owtmr-
Wilder w U have the burden of prying Nat he did nmight.ir imprve far pis of
ale.).
1�1,a owner of the property,am exclusively conraacring with li Theed..
central the project(Sec.]060,weer of and property
wWons Code:)The Con who contracts
law dos not apply a an owner of property who builds or improvss thereon, b ADING
��
Lic'.wcs for such prjws with a contrxtoKs)licettxd pursuant m the Conwcror's
License Law. � �
❑I bre exempt under Sec. ,B&P C for this reason Arr6 eo rA A/
Owncry, WORKPJt'SC06 A]IO�ECIARADTION s 1�- �S
1 hereby affirm under penalty of perjury one of Ne fallowing dechmitions:
❑Ihamandwillmainaina Ce r,.wof Comentioalf-imumfor Workeri Comuen- -
ation.u provided lar by Section YrM of the labor Code,fm Ne performance of the -
work for which this permit is cooed.
❑1 ban and will maintain Worker's Compensation Imurana,as required by Section
3700 of Ne labor Cade.for Ne performance of the work for which Nis permit is issued.
My Workers Comparwtion lnsumnee arricr and Policy number am:
Cartier. Policy No.:
-CERTIFICATE OF E%EMPIION FROM WORKMS'
COMPENSATION INSURANCE
(This wetimn need not be completed lithe permit is formic hundred dollars(Sift
or lees.)
1 certify Nat in Ne performance of the work for which this permit is issued,1 shall not
employ any Person in any '
to ams abjemoNme
ApplicantWarkers'Gompenadon
Laws of Califomia.Dare'
— /� 1 V
NOTICE TO AP :If,arm,matin Nu Cen;Omte of Eacmption,you should
become subject to the Workcri Compensation provisions of Nc labor Codc.you mus
.JO forthwith comply with such provisions or this permit hall W domed mated.
z CONSTRUCTION LENDING AGENCY
[-+ I herebywhihthi Nat Nnrtis. (Seeconstruction3W7.Cil.
agency for Nc Performance of
tx�
the work for which this permitis issued(Sec.31197.Civ.C.)
W 0 lender's Namc
z t<nderi Address
U Q 1 certify Nat 1 have read this application and state Nat Oc above infotmabun is
f], r cmrecL 1 agree m comply with all city and county onlognme and sac laws relating in
O V building convection,and hereby suNorlm mpreantatiws of Nis city in toter upon the
r W abovcmenudgm nrpcst to,impaction purpose:
(We)agree m ave.indemnify end mcp humkss the City of Cupcninm Usiw
h inconsolue ce or th,costs and cxpns permit may in any way ac"uc agalnstsaid City
UZ, in consequcnee of the granting of Nis permit.
^
SOURCE REGULAVONS.
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT Issued by: Date
4496
lent nature or JA" 7/ r
Re- roofs
g pp maHtrAZARDOUS MATERIALS DISCLOSURE ' Type of Roof
Will one applicant or future building Occupant gum or handle haardous material
as defined by the Cupenino Municipal Code,Chapter 9.12,am the Health and Safety
Code.Dy25332(a)7
es VLNo All roofs shall be inspected prior to any roofing material being installed.
Will the.application Or Wilding=u est r If a roof is installed without first obtainingan inspection,I agree to remove
pP g pa Area
Air Quality
Management P
emit hvardnm air contaminsns ss JcOncd by the Bay Arta Air Quality Mamgcmcnt
District? all new materials for inspection.
❑Yes W.
1 have mad the havardnus materials requirements under Chapmr 6.95 or the Califor.
nia HcolN A Safety Cade,$ecuom 2 505.25533 and 2553d.l undm=d Nat if d¢building
dos not currently have a meant,Orion is my responsibility to nobly the aeupsnt of the
regairtmcma ventre mast be met prior n,;aaanaaft ceniham or Ocapaney' Signature of Applicant Date
Owner ur morr d agent D„c All roof coverings to be Class"B”or better