04030165 CITY OF CUPERTINO e 2 ' "
BUILDING DIVISION PERMIT CONTI2AC�T�bR 1NI� M ' TQN
BUILDING ADDRESS: PERMITNO.
SPRIG ELECTRIC 04030165 '
OWNER'S NAME: I'61tMIT LSSl1E DATE
FAE: - SANITARY OL NO,
ARCHITECrfENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
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y08 LICENSED CONTRACTOR'S DECLARATION s Lk. Job DDSCri uOn
1 hereby affirm Nat 1 am It sed an��_dsgggpmvirn5 uof Chapter 9(commencing p
�' wlN Section]t31p7 rfDiviaionJof NC Boni and Pmfcsalons Cod"c.pdmylicenmia
� „ mmLkmnrree da 97y G/O LOBBY MODIFICATION ('ELECT)
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Z p Dale ConlBlmE4p
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AR ITE D.ECL`,A ON
s033 dcnund my plena shall M uud a�3 pptd(blic rtcnrd5
ttJE U
;u. Licensed Pmfcssionel
jD OWNER-BUILDER DECLARATION
QC I hereby affirm that 11. exempt from the Conlns CoLicense: c taw for the
O C following mason(omit t 7 ensu Business and w.dem li Code:Any city or county
$(L which tsissuance,
requires;n permit re cores the alter.I t for such
demolish,ri e a sig any tatmwre
F i
prior mitsissuance,alsontin the the applicant for suchpermit mcessigned statement
�D Nn be islicensedwit pursuant mthe pmvivisio of em ConumnseYLiccneeLe us,Code)or Sq.Ft.Floor Area Valuatio
$ (commcncingwith thereforse and
basis for
thereegedwse pion.Any
vi Code)or
.. Net he is exempt Nmefrom and dte bssu far Ne alleged exemp0on.Any violation of
Section 7031.5 by any applicant for a permit subjects Ce applicant to a civil penalty of 3 34blomAgr0 0 Occupancy Type
not more than five hundmd dollars(5500). .Cts `V'D V'�Y
❑L as line
un r of the the stru� m my cmntendes araffe gee u Nei(cele cempewness
will Pr fie work,and e: swcturt is not intended oraw do fs not a(See.too04,Busies
end Professions;Code:The Contractor's Liamand
Law does not apply ld an owner of Required Inspections
.mol who Wlldmr ed that
thercrq and wht am
wank himselred or for mleugh his
own employes,provided Nat such imps sold within
art net interceded oroRend far owner.
builder,Nebuildingmimpnvemenlissold vermin ane yearofcprovefrCeowner-
builder will have me burden of preying Net he did not build or Improve for purpose of
ask.).
❑L consumer ower of Ne progeny,,B sines and contesting Cid:i Thed o mnemes m
putoLathews not (See.in in weer of and Pnwho Wi Cade:)The Contrec tion. red /
u.
cense Lew dopa not apply je an owner of property who Wilda or improve Contra,and
who contracts for such projects with a contractor(s)limned pursuant m Ne Contractor's
License Law. Q/
❑lam eaempt antler See ,B&PCfor this rtssan
Owner Data a�
WORKER'S COMPENSATION DECLARATION
40 I hcmby aRsm under penalty of perjuryom of Ne following dwimiianc
❑1 have and will mvnW n a CcNrimm of Consent to self-Insum fm Worker's Compen-
sation,as provided for by Section 3700 of the Labor Code,for,she performance of me
work for which this permit is issued.
❑1 have and will maintain Worker's Compensation Insunnm,as required by Section
3700 of Ne labor Coda for Ne performance of the work for which this permit is issued.
C�a�Wsorkup/COs 3 Til; c aPolcyNry nu�mbaeram:
(V/ CERTIFICATE OF E% Pfi0N FR0 ORKERS
COMPENSATION INSURA CE
(This section need noticeompleu l if the permit Is foronc hundred dollars(SIM)
or leas.)
1 cenify that in Ne mr(mmarm of the work for which this Permit is issued,I shall not
employ any person in any manomm as to become subject in dm Workeri Compensation
Laws of California.Dam
Applicant
NOTICE TO APPLICANT:IL after making this Cenificau of Exemption,you should '
become subject in the Worker's Compensation previsions of Ne labor Code.you must
.J Z forthwith comply with such provisions or this permit shall be doomed revoked.
„z,i O CONSTRUCTION LENDING AGENCY
_(~ I hereby affirm that Nen is a construction lending agency for the performance of
ai> the wufk for which this permit is issued(Sm.3097,Civ.C.) _
W�A Lender's Name
zLender's Address
f J Q 1 modify that I have mad this application and nuts that the above information is
,L E' correct.1 agree to comply with all city and county endurances and scale laws rearing to
0 building convection,and hembyautborie upmunutives of this city on enter upon the
a shove-mentioned pmpcny for inpmoon purposes.
Mr)agree to love,indemnify and keep harmless the City of Cupertino against r'7
tiW liabilities,judgemms.costs andesperms which may in anywayaccrue againstavd City
V 7 mcomrgmnecofthegranlmgof Ni reit.
�i AP DE S qS ILL COMPLY WITH Ss+L N fpyt' Issued by: Date
Re-roofs
ofAho,can r Dam
HAZARDOUS MATERIALS DISCLOSURE Type of Roof
Will Ne applicant m fMun building e,Chapter
9.1 rehandle hvardous material
u defined by the CupeNno Municipal Code,Chapter 9.17,and the HGIN and Safety
Code,Seeem 25532m)? All roofs shall be inspected prior to any roofing material being installed.
❑Yet No
Will the applicant or fut ne building mcupanl use equipment or devices which If a roof is installed without first obtaining an inspection,I agree to remove
emit havandnus air contaminants u defined by the Bay Area Air Quality Management all new materials for Inspection.
District?
El Yes ^0
I have mad the hamrdms materials myuirtments under Chapter Q95 of Inc,Cables.
nia Hce"dr SaferyCode,Sections 25505.25533 and 25534.1 undenund dm irthe Wilding
is
dors h t my responsibility m note omupans of Cc
rt �m 'sstancaoracemhaamafar SignatureofApplicant Date
Da All roof coverings to be Class"B"or better