04030020 CITY OF CUPERTINO
BuaowcDrvlslory PERMIT ,Q0N?TRAG`t0k-4N)+'C11tMATIlJN
Buaomc ADDRESS: SPRIG ELECTRIC 04030020
No.04030020
R'S NAME: PERMIT ISSUE DATE
SOBPA
NE: SANITARY NO. CONTROL N0.
4
ARCHITECT/ENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
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yap LICENSED CONTRACT'OR'S DECLARATION
1 hereby affirm Net I am licensed under provision of Chapter 9(commencing Job Description
with Scomis7WlBof Division Jof Ne Bummustand Profcsslnns Code,and.1 he...is
0i infull fogvdcolow p Lk«� n REVISION- D FERRED SUBMITTALS
n�� License a V Gant use IN HOUSE USE ONLY, NO NEW PERMIT ISSUED
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Ian undmyphnaslulltZed ea Re rsnma - . #O-:#03"070068 EXPIRED/#04010069
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3 G� Limmad Prolcssional
s. OWNER-BUILDER DECLARATION
1 hereby alarm that 1 am exempt from the Contractors License Law for the
p O following reason.(Seemic 7031.5,Business and Professum Code:Any city or county
K 9 2i which minimal a permit to construct,alter,improve.demolish,lir repair any simulum
prior m its issuance.also requires the applicant forauch Permit to Elea signed suement
£ < thatheislicensedpursuanttothaprevisionoftheContmucesLicenselaw(Chapter9 Sq.Ft.Floor Area Valuation
rd,2p$ (commencing with Section TIDO)of Divison 3 of too Business and Professinm Code)or
3 that he Is exempt therefrom and the basis for the alleged exemption.Any violation of so
Section 7031.5 by any appli=nt for a permit subjects the applicant to a civil penalty of APN Number Occupancy e
not mem than five hundred dollars(5500). P y T']ye P
❑
L.owner of the property,or my employees with wages as their sole compenaston,
will do the wok,and theswaure is..Nnm,rdcd orotTemd forsaia(S.c,7W.Buainas
and Profession Code:The Colossuses License Law docs not apply to an owner of Required Inspections
propeny who builds or i m proves thereon,and who does such work himself or through his
own employers,provided theasuch improvements are not intended chaffered forsaln.If.
however,the building or improvement is sold within one year of completion.the owner.
builder will have the burden of preying that he did not build of Improve fm purpose of
sale.).
1.as owner of the property am exclusively contacting with licartsed commctou to C
consumer the project(Sec.7004,Business and Professinm Code:)The Contractera Li.
cense Law does not apply to an owner of property who builds or improves therton.and \
who contracts for catch projects with a contracusr(s)licensed pursuant in the Concurrences
License Law.
❑l amexemptunder Sec. ,B&P C for this
r Data
WORKER'S COMPENSATION DECLARATION
I hereby affirm under Penally of perjury oro of the following declssation:
1 have and will maintain a CeNficete of Consent to self-insure for Workers Compen.
action,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 Worker's Compensation Insurance,u requited by Section
37W of the Labor Code,for the performance of the wok for which this permit is issued.
My Woreees Compe�amion saran=carrier antl Pope,number am:
Canierl v p3�1�y��fdl CS 0
CPRrin A OF EXE h ON FROM WORKERS'
COMPENSATION INSURANCE
(This a=non need not hecampleted if the permit is foram hundmddollars($100)
or less.)
T certify that in the performance of the work for which this permit Is issued,1 shall not
employ any person In any mannerm as to beeomesubj=uo the Workers'Compensation
Laws of California.Data
Applicant
NOTICE TO APPLICANT:If.after making this Certificate of Esemption,you should
b=ome subject to the Worker)Compensation provisions of the labor Code,you mat
3z forthwith comply with such provisions or chis Permit shall M moment mvaked.
z o CONSTRUCTION LENDING AGENCY
[-t4 l hereby affirm that there is a construction lending agency for the performance of
N.> the work fur which this permit B issued(Sen:.3097,Civ.Q
aQ Lender's Name
r7 z Lender's Address
V Q I calcify that 1 have read this application and sum that the above information is
IL F correct.I agree to comply with all city and county ordinates and sum laws muting to
Q U building construction,and hereby authorise ripmsemtivea of this city m enter open the
,U above-mentioned property for inspection purposes
gy (We)agree to save,indemnify slid kap harmless the City of Cupertino against
fA liabilities,judgments,costs and expenses which may in any way accrua against said City
(„)7 in consequence of the Standing of this Permit.
C APPLICANT UNDERSTANDS AND WI L COMPLY WITH A NON-POINT Issued by:3 Date
Oy Re-roofs
Si tdIhcofApplicamVCOmmcIoJ Dam
US MATERIALS DISCLOSURE Type of Roof .
Will the applicant or futum bas ding accupenummarhendleha'mNausmateris
dented by the Cupertino unit' al Code.Chapter 9.12,and the Health and Safety -
.Section 35332(a)? All roofs shall be inspected prior to any roofing material being installed.
❑Yes u
Will the applicant Tamm banding accapanl tat equipment or devi=ce which If a roof is installed without first obtaining an inspection,I agree to remove
mit haxardnus air conuminU defncd by the Bay Area Air Quality Management all new materials for inspection.
District?
❑Yes u
I have rand!the haaaN rials requiromanuundef Chapter 6.95ormCalifor-
meHealth&Safety Code,secuons25505,25533 and 25534.1 undemund Ihaz if the building
docsL Na is my responsibility u occupant notify Iba of Ne
utrcmcnts what stM tssuanccofa Cc team upancy. Signature of Applicant Date
Dam All roof coverings to be Class"B"or better