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CITY OF CUPERTINO
BUILDING DIVISION PERMIT.zCONTR4CTORI�NF'OR�MATION,
BUILDING ADDRESS:
PERMrr NO04030161 4030161
OWNER'S NAME:
PERMIT ISSUE DAIS
SFC
E:
SANITARY OL N0.
ARCHITEC (ENGINEER:
BUILDING PERMIT INFO
BLDG ELECT PLUME MECH
0
LICENSED CONTRACTOR'S DECLARATION
lob Description
I hemby afllrm Nm I am licensed under provWons of Chapter 9 (Commencing
with Section 70170 of Division 5 ofthe B". and Pmfead. Cade. and my license la
D"t-
utflLice
cClass t;e.11
WATER DAMAGE REPAIR
Date Conuamor
ARCHITECTS DECLARATION
I understand my plans Asti he used a public records
,4carind Professional
{/
OWNER -BUILDER DECLARATION
T hereby fflon(Sect that 11. elempl Lata for TIM
CssionslCo
`
j
ns Cade: Any city m county
s a Pr e: Any
fallowing won. (Section ]onstr Business sed
.
demalWt, or repair any utuelute
which & cmmmun. alma, Improve. COM
epermit ."re ntprow,
its issuance.
prior bits iesund
ny)uithe the applicant for suchpermitLicense Law(wmmcm
Sq. Ft. Floor Area
Va short
Tamm Buwtoralkevelaw,Code)9
Noumea licetmd pSewanl 70tH ofProvisions sion n 3 othe f be ess and vilatio) of
(commentingwith h'OMfM 7
aemptipn Any violation of
basisfroftheeged courpton. Any
Net he Is thamfrom and the beer for
and the
314415dt@r0 0
Occupancy Type
be cu lim
31.3 b fora permit wblecu tiro applicant to a civil penally of
Section 7031,5 airy
red dant
nal more Bum rave hundred dollen (f300h
five
❑ 1, as owner of tion property, or my wployces with wages as BMG sum mmpensedon,
Required Inspections
ee
will do the work. and Neawttum ianatlnmMedaranered forsale(Sec. 70th, Budrcu
law does act apply he owner of
Tie Conuar's Llaruto
and ProfessionalCode tw
q P
propertywbobuilds or Impro ea thereon.and whodoessuchworkhimselfm Brough his
owmmrployces, provided thalamh imprommcntsue not intended maRered for sele.If.
however, Ne building or Improvement Is sold within Case year of wmpledon. rise owner.
builder will have the burden of proving that he did not Wild or improve for purpose or
um.),
❑ 1, an owner of the progeny, am eaclutively contracting with licensed eo estrus& to
counter the project (Sec. 7044. Business and Professional Code:) The Contractor& Ll -
come law does am apply toan ownu of property++ ho Wilds or improver tiMlCon. sed,
who centraw fm such projcw NN ecoalraCm(s) ICensed pursam tolhe Cenuacnr&
License Law.
❑lam see .B&PCT thi
alis am
WORKER'S COMPENSATION DE ON
1 bercby aBirm under penury of perjury one of the following decimations:
l haw and will maintain a Certificate orcomenl to self-inwm forworkeraCompeer-
setion, as provided for by Section 7700 of use Labor Code, for the performance of the
wort for which Of. permit is Intend.
❑ 1 have and will maintain Workers Compensation resonance, as requited by Section
3700 of The Labor Costs, for the performance of the work for which this permit is Weed.
My Workers Compensation Informs,: carrier and Policy number ate:
Carder: Policy No.:
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
oBr sectim reed not beeompmmd Ethic paiml, Is forum hundeeddollua (5100)
or lest)
1 certify that in the performance of the work for which this Permit is issued. I shall not
employ any penen in my mmmr an as as become wblml la use Warkcn'Compemation
Laws of Califomr. Dam
Applicant
NOTICE TO APPLICANT. IL Our making this Ccdincafe of Esemplion. you should
become subject to the Woher, Compensation provision, of the labor Code. you muss
foMwith amply with such provisions of this permit shall he decreed revoked.
CONSTRUCTION LENDINGAGENCY
Thar rending.) for use perfurmamx of
Ne then tsoed
whslam
(Sec.
be duh far which Nr permit r ivned (Sec. 3119], Civ. CJ
Lender's Nanta
Lender'sAdw
1 I certify that I have fad this application and sem that the above Information is
'
CDMCL'I agree to Comply with all city and county ordinances and state laws totaling to
Wilding conservation, and hereby sutbodre representatives of this City to enms upon Nc
abovs-mentioned property for inspection purpaet
(We) agree to an, Indemnify and keep homeless the City of Cupertino against
j liabilities. judgments. Caw and expenses which may In any way acrnM against said City
nsegueme of the Owling of this permit.LICANT UNDERSTANDS AND WIL COMPLY WITH ALL NON -POINT
Issued by: Date
3 i a
Re -roofs
-17
Type Of RoofWill
Due
HAZARDOUS MATERIALS DISCLOSURE
Nc applicant or fumm Wilding oaupn, same or handleh nsmamial
:It
nned by tie Cuperdno Municipal Code. Chapter 9.12, ad euN and Safely
. Scctian 25532(.)]
All roofs shall be ins ected nor to an roofin material beim Installed.
P P Y g g-
❑Y.Na
If a roof is installed without first obtaining an inspection, I agree to remove
Wlll the applicant or future Wilding mcupml use equipment ser devise which
hafardoua air contaminants as deRned by the Bay Area Air Quality Management
all new materials for inspection.
District?t(��
❑Ya ®No
I have read the hvsrdmsmwdalsruqubermfus underChapmfh.95 of BM Califor-
nrHnlN&SafetyCodc, Scctians75505.25 3un125574.I mdentsnE Lus ifdM Wilding
does not cmmnlly hew & umanL then it r m roganslhilitY b notilY Um oceupanl of Nc
mquim wlp t me da ran ofaccrBnamofa3 .7
Signature of Applicant Date
All roof coverings to be Class "B" or better
Ow a hon.d. en Date
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