05030026 CITY OF CUPERTINO
vx4 .� f•
BUILDING DIVISION PERMIT
C,QNT.ICOIt T tN 'ORMATI1 ,;°;
IDING ADDRESS: NOVO CONSTRUCTION "'%5030026OW NEWS NAME: PERMIT ISUEDATE
PHONE: SANTI'ARY ND. CONTROL NO,
GHTIECl/PNGINEER: BUILDING PER PL INFO
BIRO ELECT PLUMB MECH
�oo LICENSED CONTRACTOR'S DECLARATION O O O O
E9 1 hereby afflrom tha 1 uv licensed under provisions of Chapter 9(commencing Job Description
nth Section 7M)of Division 3 of the Butinea,and Professiam Code.ab my license is
m ren rens and ercea.
Lkuueasg. Lk.g _Q3`n9 REVISION—REDUCE CORRIDOR WALL
Dale '< = Contractor o.yO o newt w TO SFT. IN HOUSE ONLY-NO NEW PERMIT
ARCHITECT'S DECLARATION
oil I understand my plana shall he used as public meords ORIG PERMIT 05010040
0 u
5 Licensed Professional
OWNER-BUILDER DECLARATION
I hereby afrum that I am exempt from the Contractor's License Law for the
0 O following recon.(Secdon 7031.5,Business and Professions Code:Any city or county
$ which requires a permit to construct,alter.Improve,demolish,or repair any anucture
H� prior in its issuance,also requires the applicant for Such permit to No a signed aatemem
�< that he is licensed pursuant to the provisions of the Connector's iicansc LAS,(Chapter 9 Sq.Ft.Floor Area Valuation
qF o (commencing with Section 7000)of Division 3 of the Business nod Profeolom Code)or
6 $ that he I.attempt ire efrom and the basis for the alleged exemption.My Wolman of $636000
Section 7071.5 by any applicants for a permit subjects the applicant an a civil penalty of APN Number Occupancy Type
not mom than Ove hundred dollar($500). -
❑I,uowmerofthepmpmymmyemployeeswithwgmudeomlccmpe don,
will do the work.and theatmnum Is not mounted or oriented forsae(San.7041.Business -3Re uired Inspections
and Profusions Cade:The Contrmmora Lit....law docs not apply m an owmr of q P
property who builds or improves thereon,and who does such work himself or through his
own employees,provided that Such improvements me not Intended or offered for sola IL
however.the building or improvement 4 Sold within aro year of completion,the owror-
builder will love hk burden of proving that he did not build or improve for purpose of (`•
Sate.).
❑1.as Manor of the property,am exclusively contracting with licensed convacmn to DJ
construct the pmjem(Sec.7(144,Business and Profassiuns Code)The Contrsezera U. r _
cense law does not apply an an owner of property who builds or Improves shemon.and,
contracts for such pmjecu with a contractor(s)licensed pursuant m the Consamors
rue Law.
Son esempl under See .B B PC for Its name
;37M
er Date
WORKER'S COMPENSATION DECORATION'
I hereby affirm under penalty of perjury ane of the following declarations:have and will maintain a Cenlriatter Covent m self-insure for WorlmesCompen-
n,u provided for by Section 3700 of the labor Code,for Ne performmce of the
for which this permit is issued.
have and will maintain WarkeM1 Compensation Insurance,u required by Section
of the Labor Code,for the performance of the work formich this permit is issued
My Worker's Compensation Luumce carrier and Policy number an:
Cartier. Polley No.:
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(This section need not becomplemd If the permit isforonc hundred dnllaa($]W)
m tea.)
1 unify,Met in the performance of the work for which this permit is ismed,I Mall nes
employ any person In any manmrm as m Women subject to the Warken'Compensadon
Laws of Califomia Dem
Applicant
NOTICE TO APPLICANT:If.after making this Ceri0ate of E mouptkn.you Should
become subject to the Workers Compeuauon provisions of time ladx Cade,you mus
.JO forthwith comply with Such provisions or this permit Oat]be decreed mvelmd.
'�
CONSTRUCTION LENDING AGENCY
(—r I Morhyafllfm Nat them is a construction lending agency for the performance of
a> the worth for which Nis permit Is issued(Sec.3097,Civ.C.)
GQ Zanders Name
Q z Lender's AddnSa
V Q 1 certify that I have Send this applicaton and sore Nu the above information is
Ifr const I agree to comply with all city and county ordinance,and slow paws minting m
Q building construction,and hereby authorize mpresanutives of this city he enter upon the
Liz above-mentioned property for Inspection purposes.
LL (We)agme in Save,indemnify and keep hamlet the City of Cupertino against
I,) liabilitla,Judgments,core and expenses which may in any my accrue against midCity
fJ 7 in consequence of the granting of this permit.
FI APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT Issued by: Date
SO RCE REGULATIO
AT,� Re-roofs
nature of ApplteanUComrseror Deo
HAZARDOUS MATERIALS DISCLOSURE Type of Roof
Will the applicant or fumm building occupmulom or handle huardous material
dented by the Cupertino Municipal Code.Chapter 9.13,and the Health and Safety
cadc, Des 25533(.)? All roofs shall be inspected prior to any roofing material being installed.
❑Yes �No
Will tte applicant or future Wilding occupant tic equipment or devices which If a roof is installed without first obtaining an inspection,I agree to remove
It Imsemous air comammuns u defined by me Bay Area Air Quality Management all new materials for inspection.
ict?
❑Y S
I have mW the nnuNaumacfiai,requimmenu under Chapmd.95 of the Califon
nu Health At SafclyCede.Sectiau 25505,35533 and 25534.1 understavl ft lithe Wilding
does not currently have a te(nm that it k my Seryonsibiloy to notify the aceupans of the
mgtrinmentswnkmmLed p �elpriarmiesaaeeofaCertiOcateofoccupancy. Signature of Applicant Date
/ACk x `5 All roof coverings to be Class "B"or better rr
Owner or Summired agent Dry: