04110080 CITY OF CUPERTINO x r? � ,•" �' ^r afs< t y"'s "'
BUILDING DIVISION PERMIT L€�Usk
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BUILDING ADDRESS: ', PER "04ll0080
V
R'S NAME: PRRMIT ISSUE!DATE
ONE: SANITARY C OL NO.
ARCHITECT/ENGINEER: BUILDING PERMrr INFO
BLDG ELECT PLUMB MECH
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s L00 Z0 LICENSED CONTRACIUR'S DECLARATION -JobDescription
non _
1 bmcby arum that 1 am licensed under p sof Chapter 9(mmmmming -
nth ti on B(ID)a Dividon3ofW Busineye uiom Coda,arta my licensee
inallSte► -IS4 FIRE DAMAGE REPAIR TO ROOF/WALL/ELECT. '
Z License leu f Contractor
Dam All 1recDN CONTRACTOR: AMERICAN TECHNOLOGIES, INC
nd le P mrd
OIVIL uz
3p, Licensed colo I BUILDER
OatIam exemptf DEC ON
•]] I hereby affirm Nel 1 am exempt from this Conlrottofs Liana Law for IM
I o fallowing mason.(Sudan 71131.5,Bumneu and Professions Cane:My city or county -
$ which repuires a Permit to cnnmacl,alter.improve,demolish.or repair any structure - O
prim M is Issuance.also requires the applicant forsuch permit to file signed atatemmt Sq.Ft.Floor Area V �L��1.��
00
F that he is licensed pursuant to be provisions or the Contractor'sLimnsLaw(Chapter9
e( $ (commencing with Section 7000)af Division 3 of the Bam. it prefetims Cade)or
that he us cholum of
Section 703a ISt Ey any appliemfrom a for A Permibasis subjects dric applicant the Alleged exception.
to a civil penalty of
not am Nm rave hundred dollars($50(r),
- APN Number Occupancy Type
0 I'st awmr ortimptoperdy.win Y employees with rages AS then cele compensation. 35607027 . 00
will do the work and the strtutom Is not intended or offend floor sale(Sm;7014.Business ... .,
Required Inspections
and Proreseiov Code:The Consacmfa Limine law does not apply to an owner or
property he bulldsorimprowas thercen:hedwhoddesaceh wink himulfminnough his
awnemploynes,provided thatsnehimprovemenuueamintended mo0ercd fmsale.If.
howevsr.Nebuildingmimprovementlssoldwithinsoreyevorwmpledon,de.,.
builder w10 have the burden of proving that he did not Wild or Improve for purpose of
ale.).
❑L a°inner of the pmpeny,am exclusively contracting with limned cemramom in
mummer the pmlem(Sec.7006,Business and Professions Code:)The Commemfa Li. -
cave law does not apply to anowner of property who Wllm or improves IAertan,and - - - — — -- - --
who conduct,far Such proJetttwith°coura mor(q llavedpurswnt lathe Contrcmh
License Law.
Ell
1°m exempt under Sac. .B A,P C for this moon
At Das
WORKERS COMPENSATION DECLARATION
I hereby aBirm under penalty of perjury one of the following delamtions:
1 have end will nuimem ACeNBcate of Covent to self.insum fm We"Compeer
radon,u provided for by Section 37011 of the LaWr Code,for the patients.of Ne
work far which the perMl i,issued.
❑1 have and will maintain Wmkees Compensation hosseame.u required by Section -
3700 of the Labour Code.for Ne performance of Ne work for which this permit is iuued.
My Workers Compensation Insurance artier and Policy number am:
Corti s II .. _ . .. _
R77PTCA 0 WORKERS' - -
COMPENSATIONI URANCE
(TMs sec0an need net W completed ifthe permit is for one hundred dollars($100)
our lest)
1 ceNfy that In the performance of the work for which this permit Is Issued.I aludi not
employ Any person in any mannerso ss to become subject to the,Workers'Compensation
Laws of California.Dam
Applicant _
NOTICE TO APPLICANT.If,after making Nb CedlOcate of Exemption,you should
become Subject to the Warker's Compensation provisions of the Labar Code,you mvt
O forthwith comply with such provisions in the Permit shall W demandrcwked.
„z„Q'ICONSTRUCTION LENDING AGENCY
'[.. I tumby affirm that dtert is A consuuninn lending agency for the performance of
G'> tie souls for which the permit a issued(Sec.3W7.Cih,C.)
Q Undoes Name
7 z Lendefa Addres,
U Q 1 century that I Mw rand this appliation and sum Nat the own information is
correct.I alarm to comply with all city and county ordinesc s and some hwa relating to
prV' Wilding construction,and hereby aummum mpressummuw or this city to enter upon Ne _
ahavmmentiono l property fm inspection purposes
(We)ala m raw.indemnify and keep brimless the City of Cupertino against
WI Ilabllities.Jud enu,c vena expenses which may in any way scenic againnuia City
V 7 Ia conssquen of the n' g of Ihl anis.
r7 APPLICA NDE NDS D WILL COMPLY WITH ALL NON-POINT Issued by: Date
SOURCE U O
Re-roofs
Sg of ApplicantlContrummr Dam
HAZARDOUS Air DISCLOSURE Type of Roof "
Will the applicant m future Wilding occurred sore or handle huallous material
da 11 d by the Cupertino Municipal Code.Chapter 9.12.and the Health and Safety
.Section 25532(.)? All roofs shall be inspected prior to any roofing material being installed.
[Dy. �N
Yes o
Will the applicant or future Wilding occupant use equipment or devices which If a roof is installed without first obtaining an inspection,I agree to remove
all hA.dous Air contaminants Sidelined by the Bay Area Air Quality Management, all new aterials for inspection.
Diseicd?
❑Yes &No
I hive mW the Wvanlous materials requiremmuunderCNpter6.95ofds Califor.
oat HS.1dh Garmy a Secaav 05.25533ux125534.1undentandthuirNe Adidas L�
does nal m ally tcn°n4 it a my rcepovihilily to ncdl'y rite occupant of the
requirons whic�ubemel aitseanmof.Certificate croalma lure of Applicant Date
w yeaotnarix argent D e All roof coverings Class"B"or better