05020017 CITY OF CUPERTINO ,r�, '>' �r'?
BUILDING DIVISION PERMIT ";�CINTRA. OIi�INFQRMATIO
RD
INC ADDRESS: PERMIT N4.5 0 2
0017
OWNER'S NAME: PERMIT ISSUE DATE
PHONE: SANRARY 0. CONT0.0L N0.
CHIIEC IFNGINEER: BUILDING PERMIT INFO
BLDOO ELECT O PLUM MECH
O �
LICENSED CONTRACTOR'S DECURA71ON Job Description
1 Wmby aRm Nn
trI sue licensed under provisions of Chapter 9(commencing t
r� whs Secdoa 700D)of Division 3tr1'the Bualma and Proketaknt Cade.and my lie.is
In full farce and effect.
Lgae LDeneCiaas c��r REVISION--BATHRM & COVERED WALK
ARCHITECTS DECLARATION NO NEW PERMIT ISSUED/ ORIG. #04090297
1 undcrwnd my plane shall W need as public records
G Licensed Professional
OWNER-BUILDER DECLARATION
I hereby affirm that 1 am exempt from Elio Contractors License Law for the
1:0 O following mason.(Scetion 703 1.5,Bust•^..and Pmfessiuu Code:Any city in county
un$ which acquires a pnmh to construct,alar.Improve,demolish.or repair any structure
F�Se prior m in issuaree,also requires the applicant for each remotion file a signed statement
G thathcialicensedpursuanttotheprovisionsoftheCommon'sLiccom1aw(Curner9 Sq.Ft.Floor Area Valuatinl5
$ (commenting with Section700M of Division 3 oflhe Bwineuand professions Cak)or
Nat he is emmpt therefrom and the basis for the alleged emmptitrn.Any violation a(
Section 7031.5 by any applicant fa a permit subjects the applicant to a civil penally of APN Number Occupancy Type
not mom than firo hundred dolWa(5500).
Q 1.uawmrarN pmpenymmycmpioyewwiNwguutheemlcce pensadon, 36640003 . 00
will de the work and the immure Is notintended m offered ferule(Sec.70th,Business
and Professions Code:The Connmmr,Lkanse Law doer rot apply to an owner of Required Inspections
am enywho yees, daaded that inch lmpm ndwho daeaaoan wart Mmffered h r ighsite his "�
own cmployeWildinorithatument is old withiwmcnmmn
not year
dedarartcred for Weer. / \
hander the building orimpmromanlishath he
oro Wear of mmove for the purpose
of
builder will have W burden of proving that ha did not Wild a Improve for puryom of \
ask.). ��
❑I,as owner of ct pec.704 am eacluaively contracting with:)TM Ccanuacmn to
Construct the project(see.a nor and Ro(utltrns Cade:)M Canumrofa Li-
coast v
e Lawd nwnpplym mowoer of property ho Wilds or improwethencn,and,
o u such Froje Imaeon Ilmasedpura...I m me Ctrnlrminra
wa aw.
am excon u S ,BB PC for thin
O
RKER'S CQ) ENSATION DECLARATION
emby affirm under penalty of perjury am of the following declarations:
I hero and will maintain a CeNficam of Consent m self-into¢far Worker.Compen.
n•u provided for by Section 3700 of the labor Code,for the performance of the
for which this permit is ivied.
❑1 have and will maintain Workers Compensation
Insurance,u requited by SecOan
3700 of the Labor Cade,fat the performance of the work fm which this permit Is Issued.
My Wmkeru Compensation Inure¢carrier and Policy number am:
Cerner. Policy No.:
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(Thu men rrQmakcanpleudifdepmeakisf r trach dellan(SI00)
"real
k ry R//
1 fY that in Oc arm oft o far whi is I u issued.I Mail not
I% em rue n ymanners eco¢ just rken'Compensadon
Lawsofcali0 n
Applicant
NOTICE APPLICANT:If,arm,making thCenlOcam of Pwription.you mould
became Jett m the Worker's Compensation provisions of the labor Code,you mune
.,O forthwith comply with each Provisions or this Permit shell W deemed mvakcd.
CONSfRUCfION LENDING AGENCY
[•+ I homey anlrm that there is a construction lending agency for the performance of
me work for which this permit is issued(Sec.3091,Civ.C.)
W�C Lender's Name
z Lender's Address
U0 I really that I haw read this application and hum this Ilia shove information is
W tartest.I time to comply with all dry and county ordinances and sum lam relating to
0 Wilding construction,and tramby authodm rcprceenwivns of this city he enter upon the
W above-mentioned property for lupenion purposes
a (We)agree to have,im menIy and kec barrel the City of Cupertino against
fry Iiabili nm,cwm andl.=whic may any mymorse againumid City
C)7 _-quence me gmming of is pehe
APPLICANT RST AND LL M Y WITH ALL NON•POINT Issued by: Date
x U no �.
3'Z"0 6— Re-roofs
Signa}rc of ApplicarVOminecmr Dam
1
HAZARDOUS MATERIALS DISCLOSURE Type of Roof
Will tha applicant or fuwm Wilding occupant store or handle huardons material
depend by the Cupenino Municipal Code,Chapter 9.13,and the Health and Safety
cads.Section 25533(a)?
[3y., C]No All roofs shall be inspected prior to any roofing material being installed.
Will the applicant or future building occupont um equipment are dcvicu which If a roof is installed without first obtaining an inspection,I agree to remove
It hit draw air conmminanu u defined by the Be,Area Air Quality Managemcm all new materials for inspection.
nein?
❑Yea 0 N
I have reed lheh rduwmmdiumquimmen nder hapmr6.95ofthe Califor.
nu Health@Sa(etyc 3550. 533annl 34.1. rstmWthatifthe Wilding
ons molto
mutational l he a nanth my mspo Nit n y the occupant of the
me when fn I ivu C fOcc.pancy.<' Signature of Applicant Date
G
owwrar ware riaca seem — Dam All roof coverings to be Class "B"or better
r _