03120029 CITY OF CUPERTINO """" � '�`�`°` t a
BUILDING DIVISION PERMIT �CONTRAC'�TOR�INF®RMA N
BUILDING ADDRESS: PERMIT N0.
03120029
' R'S NAME: PERMITLSUEDATE
N
SANITARY OL N0.
E:
ARCHITECrfENGINEER: BUILDING PERMIT INFO
ep BLDG ELECT PLUMB MECH
+lpp LICENSED CONTRACTOR'S DECLARATION O O O
MM�Y F 1 hcmby affirm than I me licensed under previsions of Chapter 9(commencing Job Description
with Section 70(X1)of Divislon 3 ofthe Business and Professions Code.and my license is
in full fora and effect.
ngz LicenseClass
Lle0 Y"r ADDITION ✓(/t
2004
qqq
ARCHrfF.CrS DECLARATION
1 t nder est my plates shall be used as public racmds
7 U
jQLicensed Pmfcssianel I�
OWNER exempt
DECLARATION ■
0 f I Wmby aRrm that 11. cxcmpt from Ne Convenors e:Any c Law for the M
S:p O following reason.(Some.7(131.3,Business and Professions Code:Any city or county
which requires a Permit um cowmcr,eller,improve,demolish,or repair any umctum
prior w ila iamme,Mm squirm theepPlimnt for inch permit To Rle a signet mwmem
Thar heis licensed pursuant to the provisions of the Contriver's License Law(Chapwr9 Sq.F[. Floor Area Valu Uon
WiFF (commencing with Sudan 7000)of Division 3 of Ne Business and Professions Code)or
g g Net he is exempt therefrom and the basis for Ne alleged womption.Any violation of
Section 7031.5 by any applicantfor.permit subjects the applicant to a civil Penalty of 3 rJ glgl�erOp Occupancy Type
nal mom Nan five hundred dollars(SSW).
❑I,uowneroftW prepmy,Ormyemployees with wages u theiraeriecompti adsm.
will do the work.and he svunum 4 not intended or offered far We(Sec. Business Required Inspections
and Prefessions Code:The COmruwrs License Law dam vel appe nsly w.n owner or q p
property who builds or i mpreves 0wrcon,and who doss arch work himself or through his
own employees,provided that such impmwmmts am not Intended oroRemel furale.If,
however.Ne building or improvement is ecoid within one year of completion.Ne owner.
builder will have Ne harden of proving Nu he did trot Wild or improve for purpose of
vele.).
;who
u Owner of Ne property,am exclusively convening with licensed convenors ro
ract Ne project(Sec.7014,Business and Pmfmalons COtle:)The Convacwb Lt.
C. law does not apply sem.,of proportywh.Wild.mIrepmwa Neeson.end,
ontracts far such prejects with a monasterial licensed pursuant w du Contractor's
w.
a psundet$f .B&PC for ts on DauWORKER'SCOMPE SAT1Of CLARATION
Thereby arm uder penalty of perjury ore following decimations:ave and will mainWn a CCrtineate ofConserv to self-insure forWorkersCompen-
.u provided for by Section 3700 Of Ne Lather Code,for Ne perfarmana of the
work for which this Permit is issued.
❑1 have and will maintain Worker's Compensation insurance,as required by Section
3700 of the Labor Code.for he performance of the wort for which Nis permit is Issued.
My Workeh Compensation Insunna carrier and Policy number am:
Carrier: Policy No.:
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(Thuseedon need not W complerN limit,Permit is foromhundred dollar(SIM)
or leu)
I certify that in the performance of the work for which this permit Is issued.I shall nm
employ any potion In any manner an as in become subject to the Workers Compenation
Laws of California.Date
Applicam
NOTICE TO APPLICANT:If,after making Nu Ceriifmmw of Exemption,you should
become subject in the Workers Compeuetion provisions of the Latar Code,you most
.J Q forthwith comply with each provisions or Nis permiuhall be deemed revoked.
r CONSTRUCTION LENDING AGENCY
[r I beroby affirm that them is a conmuctino lending regency for the Performance of
ai 7 the work for which this permit is issued(Sm.3097,Civ.C.)
14 QLenders Nurse
Lenders Address
V 0 1 certify that 1 have read this application and slaw Net Me above Inforreadun is
{t, buim0.l agree to comply with all city and county ordinances of and saw[am mining e
W ilding construction,and hereby"mhon to mPrmenutives of This city to enter upon the
W shave-mcmioncd property far inspection
mnify an purposes
rA (We)a gree to cow,indemnify and which
harmless the City of Cupertino s ageing
y inmetiesjutlgmenu,emtsag es Pensesmit. may in my way acerae agelnstWdCity ^
(„)'Z in corvegmnee of the grating of this permit.
APPLICA UNDERSTANDS AND WILL COMPLY WIJiIrALL NON-POINT Issued by: Dale
sO
n
Re-roofs
Sign m of Ap"werVConveclor Date
HAZARDOUS MATERI DISCLOSURE Type of Roof
Will the applicant or Tutors W Ilding occupant nom orlundle hvardous material
u dented by de Cupertino Municipal Code.Chapter 9.12,and the Health and Safety
0y.y.23332(.)7 All roofs shall be inspected prior to any roofing material being installed.
Ym
Will the appllcan ,r rust re building Occupant use equipment or devices which If a roof is installed without first obtaining an inspection,I agree to remove
It b.r.Mnus air ronuminanu u defined by Ne Bay Am.Air Quality M....omen, � all new materials for inspection.
DIWICIT
❑Yex
I have real the h., crus materials requirements under Chepur 6.95ofheCaller.
niaHcalh&SOfetyCOtic,Scedom 35505,35533 and 25534.1 undetitsnd Mail&Wilting
Jae not corm h how.anent MO h is my respomibility w m or the mcupal of Nc
TO wh'hmus or MOT ammo Oraceninmworaeap ey. Signature of Applicant Date
mt Date All roof coverings to be Class"B"or better