05010155 CI TY OFCUPERTINO
BUILDING DIVISION PERMIT' s(e�NT'RA4"T'pR INtMATTU ;
BUILDING ADDRESS: PERMIT Nfl 5 010 155 55
NER'S NAME: PERMIT ISSUE DATE
vHE: SANITARY NO. CONTROL NO.
ARCHITECDENGINEER: BUILDING PERMITINFO
BLDG ELECT PLUMB MECH
�00LICENSED CONTRACTOR'S DECLARATION O
1 hereby M.TNI I am licensed under provision,of Chapter 9(commercial Job Description
n� with Section 700J)of Division of the Business and Profcuina Cook.rod my licensela
in full forte and eflect.
'qz umarcoas. LIc.w REVISION--IN HOUSE USE ONLY
-- Date Contractor NO NEW PERMIT ISSUED/ORIG. #04070044
ARCHITECTS DECLARATION
r Iunteralandmyplans mail heused uPublic records 2/1/5 MASSOUD SPENT 4HR ON PLAN CK-ADDED 3 MORE
c Licensed Professional
OWNER-BUILDER DECLARATION
i A g I hereby affirm that I are caempt from the Contractors License law for the
following ration.(Section 7W 1.5,Busineu and Profession,Code:My city or mounty
$ which requires a Persalt to ctmumct,alter,improve.demolish.or repair any structure
prior to its iaw«c,also requires the applicant for l«h Permit In file a signed sutemrnt
££ < dal he is limnsed Purmant to the provision,of the Communes License Law(chapter 9 Sq.Ft. Floor Area Valuation
C $ (commencing with Section 7000)of Division 7 of the Business and Professions CMe)or
3-
that he u tN
exempt mfrom and M
Bm main for door alleged erempllan. y Acted on of 0
Section 7071.5 by any applicant for a permit subjects the applicant to a civil penalty of APN Number Occupancy YY,
nal mom down five hundredeallasa(5500). P yTyne
Cl I,as owner orthe property,or my employees with wale as their tole compensation,
will do the work.and the structure is notinuendetl oronered imus,(So..7044.Business 316020413 . 0
and Profusions Code:The Commerce,Liceae Law tl«s Tal apply to an owner of Required Inspections
property who builds orlmprovm Narcan,andwho doen«hwork himmlfor through his
aweemploye al provided that such Improvements am cot inmaied"onered for sak.If,
however,the building or Improvement is sold within one year of cmmpledon.the owner.
builder will have the burden of proving that he did not build Or Improve fa pwpore of
ate.). \
❑I,u owner of the property,am maclwively contracting man Iicenad can onom,In
construct the pmjm(Sec 7044,Business and Profession;Cade:)The Contracra's U.
am Law docs not apply man owner of property who build,Or impovea demon.and
Eram for such projects,with a emlra7m(s)licensed pumum cede Contrmoes
Cnse S ILoW.
tan accept sea .B @PCfardds rtamn
r Data -Zn5
IF 0 OMPENs NDECLARATION -
1 hereby Mom under penally of perjury one of the following declamtiow:
ave end will maintain n Cmdri au of Conant m sel6Wum for WmIne.Compen.
,u provided for by seNan 7700 of the labor Code.for doe performance of the
for which thh pemil b iaued.
ave and will maimmn Worker's Compensation Itnumm,u required by Section
of the Labor Code,far the performance of the weak for which this permit Is burns.
orker,Compeaatim Torrance curia and Polity number art:
Cosier. Policy No.:
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(Tds eecdm reed cot hecompleled ifthe permit s,foro«hundred dollats(3100)
m Itis)
1 unify that in doe performa ce of the work for which this Permit is Ise«d.I shall not
employ anyperwninay manner n a obamme mbje da the Worken'CamMn,Non
Law,of Callfomia Dam
Appllcent mire 4 /W,
NOTICE TO APPLICANT.If,after making this 0 sit tote of LAImr io d you should
w,lZbecome SUbjeCt y the Worker',Coon or this pmvhlaa of the Nhm vnde,you meat
, forthwith comply with such pmvialna or this permit shall hed«mrA revoked.
z CONSTRUCTION LENDING AGENCY
E4(.v T for which
themem hacoawmnn lending agency for du Pcrfumene of
Qi me work for which Nu permit Is issued(s«.3097,Civ.C.)
GLenders Name
7 2 lender,Addmu
V Q 1«rdfy that I have And this appiiation and rude TNI the above information is
LL,^ rnmtt I agme On comply with ail city and county ordinance and same lawn rattling to
Q kSJ': building construction,and hereby wdomise rtpAumft1sves Of Ads city to enter upnn me
W above-mentiorcd property fm WPecmn purposes
6. (We)agree mum,indemnify Nd keep huintear Oe City of Cupenino apical
y IlabbliticsJudgmenu,cauandexpemes which may in aywayaccme apiutaid City
t,1 in conxgmnce of the Sterling of this permit.
APPLICANT UNDERST DS AND WILL COMPLY WITH ALL NON-POINT Issued by: Date
SOURCE REGULATI
Z-2-U5 Re-roofs
Signaurt of Applica mr Date
HAZARDOUS ATERIA SCLOSURE Type of Roof
Will doum e applicant or forbuilding amu t non,or handle husNom material
u dented by the Cupertino Municipal Code,Chapter 9.12,and the Health and Safety
u.,se❑danYa 35573(.)7 / All roofs shall be inspected prior to any roofing material being installed.
IIWill ft applicant NI nt NmIllldln8 occupant tic equipment or dcvlw which If a roof is installed without first obtaining an inspection,I agree to remove
I haoardow air conamiana as defined by the Bay Area Air Quality Management all new materials for inspection.
District?
❑Yes NO r
1 haw mss the hasrdws\maenau requirements undcrCNpm6.95 of doe Califon
Ala Health&S fmyCodc,Smimr 25505.25533..12553/.lurnim uM douifine building
does not currently hew a mall,mal it u my msponsibility or notify tie occupat of the
rcguircnen hich cera he tminiormksruanceor,cerdfieaa oraapamy. Signature of Applicant Date
Z -�mer-or• ,orad, m pate All roof coverings to be Class"B"or better