05030274 CITY OF CUPERTINO '�"� .. - "'"'f�` °
BUILDING DIVISION PERMIT IC(1NTRACT,';Rt NCORM L
DING ADDRESS: NOVO CONSTRUCTION PER "'05O30274
PTZ..qTTT,Tq WAV
ER'S NAME: PERMIT MUE DATE
PHONE: SANITARY OL NO,
ARCHITECT/ENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
O O O
�00 LICENSED CONTRACTOR'S DECLARATION lob Description
1 hereby aflirtn Nil 1 am licensed underP
provisions of Chapter 9(commencing
with Shown 7")of Division Sof the Business and Profcaalau Co@,and my license 4
in wmnwdeREVISION--IN HOUSE USE ONLY
ate f 11 f mrterz
Lae.Clap g 4D
Dew Conueror �k ncm� NO NEW PERMIT ISSUED ORIG.. #05010040
ARCHTIECf 5 DECLA Al
i underwnd my plans Mall he used as public records
U
5 lid L'wensed Professional
Oat I am exempt
from
DECLARATION
a 1 hereby,a01me on 1 I.S.uompt from tha Conunctor's License Lew for the
1 D oo following moon.Permit
t ]IDIBusiness wtl improve.
de up Cade:Any city or county
k 4. priori its Woes an,shlra CmtRNeLste�.Nforsuh Perlin care a sig my ed wment
WWF STI prior w its tensed e,a sc n,to me Ne applicant for Cols permit m file•signed auwmem
that mencinnwitpurwinrdthoofDiviomofthe eBuwwfaLwemmLaw(Clmpter9 SQ.FL Floor Area ValuaClOn$35
$ that he Is exempt Section 7000)ofbondsmrofthc Business and Profession,Code)or
tion o w 31.3 b thmerrom and the basis rte Ne siwgcd exemption.Any l peroon or
Seton]0.31.3 five
hundred
spoliate for a pormlt subjects the appllcwt nc a civil penalty of APN Number Occupancy Type
not mom Nm Rw huntlrtd dollps($500).
❑I,as owner of the property.Or my employees with wages as their sole compensation, 35720042 . 00
willdo six work and thesWcwmunoI wedged ora@red for ssw(Sec.]Ol4,Busircss Required Inspections
and Profeuiau u
Code:The Commences Ucee Law dues tew et apply an owner of Q P
property who builds or im proves thereon,a nd who does such work himwlf or through his
van employees,provided watauch improvements are not intended aro@red for sale.if.
however,the building or improvement issold within new year of completion,the owner.
Wilder will haw the Induction of proving that he did not build or Improve for purpose or l\
sslo.).
❑1,as owrcr of the property..Business esa d conuacOng wide*The Cconlracncrs w \
edosmam the esonot (Sec.]OM,wer and ny whtiop Cade:)M Cs uaewes Lb f�
cense Law does not apply je an owner or property who builds or improves thereon.and V
canLa<ts for nosh projects with aconuemr(O licensed pursuant In Inn Convacroea
Law,
am osteon antler See .B&PCfm Otis reason \\
r Date v
WORKER'S COMPENSATION DECLARATION
j l kmby Lflhm untler pe ly of p Burymm of We followlnt�lmdom:
0 I haw emd wlfi rm nwin acindfim waf Consent w wl6huum rorworkeescompem
salon.ss provided for by Section 7]00 of the Isbos Code,for tho perfonnmme of dm
work for which this permit is Issued.
❑1 haw and will maintain Workees Compensation Iuunnce,u acquired by Section
3]00 of the Isom Cade,for site performance of the work for which this permit is Wund.
My Worker's Compensation Insurance carrier and Policy number aw:
Cartier. Policy No.:
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
Clbm section need not In,completed Ifthe permit w fmaw hum bed Oil=(1100)
or Ina)
I certify that In the performance of the work for which this permit is bound,I shall not
employ any person in soy mwnerw as to become sub)ecl to the Worker'Compensalmn
Laws of Cslifomia.Daus
Applicant
NOTICE TO APPLICAND If.after making Oils Comfiaw of Exemption,you should
became subject in the Worli Compensation provisions of the Ichor Code,you must
.,O foMwith comply with such provisions or thin permit shall be deemed nevmked.
„zy CONSTRUCTION LENDING AGENCY
[r 14 I homby oflirm that them les emmructon lending agenry for rhe performanceof
> the work for which this permit is issued(See.3099,Civ.C.)
W G Lenders Name
Z)z Lenders Address
V p 1 certify that 1 have mad this application and stow this the show informed.is
I,Frect.corl agree on comply with W city and county ordinances and awe laws relating he
C V Wilding copuunion.sod hereby wthodon repmsenufivela this city ncenb upon the
til abovomemdoned property for mi codon purposes.
FC+' (We)agree to an.indemnify and keep harmless we City of Cupertino against
res
liabilities,judgments.costs sod eapenan which may in any way seems against mid City
C.3 in consequence of the gaming of this lermil.
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT Issued by: Date
SOU CEREGULATIO .
in AAM-a 3/ag�o�i Re-roofs
L"ure ofAppli III ARDOR MATERIALS DISCLOSURE nvcmumad, Due Type of Roof
WIII site applicant m rpwm building aaupantswm drhandle hassNaus material
defined by the Cup�Nno Municipal Code,Chapter 9.12,and the Health and Safety
.Section 253324)? All roofs shall be inspected prior to any roofing material being installed.
❑Yn
Will the applicant or uwm building occupam me equipment at devices which If a roof is installed without first obtaining an inspection,I agree to remove
emit hasudmis air contiminwts in defined by the Bay Arm Air Quality Management all new materials for inspection.
District?
❑Yes SO
I haw road the hpardnus materials requirements under Chapter 6.93 of the Califon
nu Hcalth&SafetyCode,Smites 23303.25533 and 25534.1 undersued mad due building
does not currently Mw a imam.too It u my ruponslbility W oddly IM aaupet of de
requirements which edmet pdorw ismawc ofs Certificate of Occupanry Signature of Applicant Date
K4dEn♦ o L 3f-Zy/�75 All roof coverings to be Class"B" or better
Owner or amhone"spot Date