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04030069 CITY OF CUPERTINO m - - BUILDING DIVISION PERMIT C©NTRACT4 R INkC1RNIATIgN BUI LDINGADDRESS: - PERMIT ND04010069 210 12RITNT�RlPrR NER'S NAME: PERMIT ISSUE DATE ONE: - SANITARY NO, CONTROL NO. ARCHIIECTIENGINEER: BUILDING PERMIT INFO BLDG ELECT PLUMB MECH YOo LICENSED CONnRd under DECLARATION b 1 hereby affirm dm I am licensed under provisions of Chapter 9(commencing Job Description _m with Scction ndefe(Division3of the Deal ncvund Professions Code,end my license is in in full Intoe and effect. iq3 License Class Lac.as TI-1 STORY LOBBY REMODELING & 'i Data Contractor ECL EXTERIOR LANDSCAPE ARCHITECTS DECLARATION J (understand my plans shall M used as public records ORIG. #03070068 EXPIRED/ PAY 1/2 PERMIT FEES yq 0 Licensed Pmfeesienel or OWNER-BUILDER DECLARATION g<f 1 hereby affirm that I am exempt from the Contractors License Law for the p o following mason.(Section 7031.5.Business and Professions Code:Any city or county .. sg which requires a Permit to construct,alter.improve,demolish,or repair any structure Ply poor to its issuance,also requites the applicant for such Permit to file a signed statement FC that he is licensed pursuant to the provisions of the Contractor's License Law(Chapter 9 Sq. Ft. Floor Area Valuation (commencing with Section 7000)of Division J of the Business and Professions Code)or that he is exempt therefrom and the basis for the alleged eure,him.Any violation of $300000 Section 7031.5 by any applicant for a permit subjects the applicant o a civil Penalty of APN Number Occupancy not more man Bre ane hundred dollars p y Type ❑1,as owner of the property,or my employees with wagesu their sole compemadmi, will do to work,and me ancien is not intended or offend for sale(Sec.7044,Business and Pmfessions Code:The Catnmctor's Licerue Law does not apply to an owner of Required Inspections property who builds or improves demon.and who does such work himxel(or through his own employees,provided that such improvements are not intended or offered for sale.If, builder to,buildingburden Improvementis sold hediinone but Id of completion.for Ns owner- ' builder will haus the burtlen of proving mu he did not build or improve for purpose of k1,as owner of the property,am exclusively contracting with licensed canoactars to stmct the project(Sec.7044,Business end Professions Code:)The Contractors Li- who con w does not apply to in with z of property who sed p or pursuant to demon,and who contacts for such projects quid a mnvutor(s)licensed puauam m dm Contractors L'mcnu Law. / ❑late ezen to msec. ,B&PC for this reason 14 Z mer WORK R OMPENSATION DEC ION Ih chy affirm underpenallyofpedury one ofthe following declmtumnes: x Ihav and will maintain a Confronts.o(Conscnuo self-insure for Worker Compcn. , cation,ss provided for by Section 3700 of de Labor Code,for to performance of the work for which this permit is issued. ❑1 have and will maintain Worker's Compensation Insuan n.u required by Section 3700 of tha tabor Code,for de performance of de work for which this permit is Issued. My Workers Compensation Insurance carrier and Policy number an: , Cartier Policy No.: _ CERTIFICATE OF EXEMPTION FROM WORKERS' COMPENSATIONINSURANCE (Thu section need not becompleted if the Permit is for one hundred duRim,IS 100) or leas) 1 certify that in the performance of the work far which this Permit is issued,I shall not employ any person in any manner so as to become subject o the Workers'Compensation Laws of California.Data Applicant NOTICE TO APPLICANT:IL after making this Certificate of Exemption,you should become subject m de Worker's ComPereelion provisions of the labor Code,you must .JO forthwith comply with such prnvisions or this Permit shall he deemed revoked. - .zi " CONSTRUCTION LENDING AGENCY N I hereby affirm that dere iss ed(S .3 7,Co,{agency for the performance of ai r7 Le work for which this pennil is issued(Sec.]097,CiCJ D Q Lenders tame - � z Lender's Atltlmu U Q 1 certily that 1 have read dis application and sum that the above informade.it !!. H correct.1 agree to comply with all city and county odinameas and ionic laws relating to C U building construction,and hereby amharive reprcuntetives of this city to crime upon the W shove-ex.Judnetlpmperst(an expenses purposes. y (We)agree to Sam.indemnify and keep hssmless the City or Cupertino against rZ Iiabilitiea,Judgmc th cosBmtl*AiS expenses which they in any way eccme against said City - U z incan uyuc cc of do gramin is mit. APPLICA U ERST AN WILL COMPLY WITH ALL NON-POINT Issued by: Date SOURCE EG ATI t I i !/O 7 Re-roofs t of Applica Contactor Dan HAZARDOUS MATERIALS DISCL SURE Type of Roof Will the applicant or fMuni building occupant r9,1 or handle Health and u ticfincd by de Cupertino Municipal Code.Cheerer 9.12,and me Heald antl Safety da,radon 25532(.)+ All roofs shall be inspected prior to any roofing material being installed. ❑Yea V. Will the applicant or future building occupant use equipment or devices which If a roof is installed without first obtaining an inspection,I agree to remove tit havardous air contaminants as,defined by the Bay Area Air oust fly Management all new materials for insp etio . isvim7 ❑yea No - Ihavemaddeh.coximsmamri smyuimmcnts under Chapter 6.95 of the Calif., _ ria Heald&S ty ,Scction 50,25533 enJ 25574.1 undcrsmntl thmifdc building does not cure lya ten of 1 my responsibility m nodl'y the..,.tof de rcyvimmcns hic ort - poor too cof.cioirio.w.fMSignasureo ppl ant Date Owner or ori,.eda ret Date I/ Allroofcoverings to be Class "B" or better