05120149 CITY OF CUPERTINO
BUILDING DIVISION PERMIT .�CONTRACTaR INFORMATION „
d J' - ?rh^ ;;..1, r..x..Y+ t..,f:Zur^ bst-%x.s:a�,�'4•,,>,
BUILDING ADDRESS: PERMITNO.
05120149
O E: PERMIT MUE DATE
SANITARY N L NO.
C '
ARCHITECHENCINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
i p LICENSED CONTRACTOR'S DECLARATION Job Description
C 1 hereby affirm Nal I em limned under provisions of Chapter 9(commencing P o
? wish Section 7")nf Division 3 ofd¢Business and fessmna Code,and ylim.is
I Tau forte and erten.(/s 7� Il'Ly
;? License cl L Lic.P CONSTRUCTING TWO ARBORS AT REAR YARD
Da, Canlmcbr "�
ARCHTIECf S DECLARATION
j_; I mocrau deny Plana:hallk used sorubra menms
U
m Licensed Professional
.S OWNER-BUILDER DECLARATION
S I hereby affirm that 1 am exempt from On Conuanors License Law for the
1 o following anon.(Section 703 1.5,Business and Professions Cede:Any city of county
3 which requires a Permit to construct alar,improve,demolish.or repair any structure
;y prior In in issuance.also roqume,the applicant for such permit o fileesigned sulement
ea that he is:iconsedpursuentintheprovisionsoftheConammr'sLicenselaw(Chapter9 Sq. Ft. Floor Area .Valu
-ct (commencing with Section 7000)of Division 3 of Lk Business and Profednns CMc)or
$ taut he is exempt therefrom and the bssu for the alleged esamintion.Any violation of
Section 7031.5 by any applicant for a permit subjects On applicant to a civil Penalty ofs py�i
nm moa .love hundred dollars(55(10). 3�-rl;+rTltmbP.r tutu ' Occupancy Type
p1.a owner of ft property.m my employers with wages a thaw auto rompenarkin, OOJO111V
will do On work.and the structure is not intended or Oriented Imola(Sec.7001,Business
and Profevions Code,The Contractor)Limme taw does not apply in an owner of Required Inspections
cove
property who s,provi imprmms tkreon,and who do sat ma mkhimselfm through his
ownemployee,provided pr suchimpmwmwtart not ear of completion.
fm Owner.
bmvewm the building or improvement is sold within oro yearofcompletion.Ne Owner.
of
builder will kw die Wrdesr of proving Wt k did not build m improve for purpose of
❑1,as owner of ct property,am exclusively contracting with licensedTh,Ceonume, b
cents La the prolan(Secapply
,im Baines and Professions ds oron, ve,ft...ail
cense law dors nm apply m is owner of properly who builds or improves daemon.and j
who conuaco for such projcco with a cemacmrtq licensed puravem to the Convenors
Lwonm law.
1 em exempt under Sec. .B d:P C fm Nu reason
Owner Dale
WORKERS COMPENSATION DECLARATION
1 hereby affirm under penalty of perjury one of the following decimations:
I have and will maintaina Ce fiowofCarucnuomtf-inumforWorker'sCompen-
station,as provided Ire by Section 3700 of ole Labor Code.for Ile Performance of Ne,
weak for which this permit is issued.
❑I have and will maintain Worker's Compensation Insurance.as sequined by Section
37W of the labor Code.for Ne famformantt offt wort for which Nis Permit is issued.
My Worker,Cnmprnsmime Insuance ceMinimal Polity numhe,itre:
arrwr:�(ivy.^!— 1�o - Policy No.:3 e D a 00'-
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(This section need nor be compacted if de permit is for one hundred dollar(SIM)
er less.)
1 cmify thm in the perfmm rim of the work for which this Permit u issued,i shall not
employ any person in any unionism ra in become subject to the Workers Compensation
Laws of California.Data
Applicant
NOTICE TO APPLICANT:Ir.after making this Ccnibate of Exemption•you should
become subject in the Worker)Compensation provisions of NC Uner Coke.you must
Oforthwith comply with such provisions to this pcoult shall be dectlled revered.
CONSTRUCTION LENDING AGENCY
I hereby affirm Nat Nem is a construction lending agency Tor Ne performanss of
an,work for which this permit is issued(Sec.3097.Civ,C.)
0 lender's Name
z Lenders Address
Q 1 cmify Net I have road this application and soon Nat NI above information is
Fmoron I agora to comply with all city and county on inance[and seats laws misting to
V Wilding construction.and hereby noshafia representatives of this city to enter upon Ne
(in
LV above-mentioned judgments.costs
and epauses purpowhich a
s.
gy (we)agtce m Osis,indemnify and keep harmless the City of Cupertino against
h incoitiesuctum f thecastaeng oftcnseemit. may in any my theme against said City
A APPLICANT
of the granting SNis permit. �_ /
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON OINT Issued by: Date 4
SOU�RCE ^UTATIONS.
l._ _ '4�7 n l 'Re-roofs ,�-'-
SignetureofApp:rcmVConuact T w
HAZARDOUS MATERIALS DISCLOSURE / Type of Roof
Will the applicant or future building occupant nom or handle havudous material
Us dcrined by the Cupenum Municipal Code.Chapter 9.12,and On Health and Safety
Code.Section 25532p)?
All roofs shall be inspected prior to any roofing material being installed.
❑Yes W.-
Will[be applicant or future building Occupant use If a roof is installed without first obtainingan inspection,I agree to remove
PP g P ea Air
which P
.n ict? tax sir contaminants a defined by Ne Bay Arca Air Quality Marogcmem all new materials for inspection.
[tAsuin7
❑Yes XINU
I have mad the hvtNwsmaterials requirements under Chap¢r6.95 of the Ca:ifor-
iixHealth ASefctyCWe,Sections 25505.25533 and25534.1 Understand that It ilding
dors not currently haw a wool Nat it is my responsibility to rmdfy tk ecu t of plc
11�u' u which mum be mel Prior In issuance oft certificate or Occu Signature of Applicant Date '
Owner or aeNnn.ea gent ,m All roof coverings to be Class "B"or better