03110134 CITY OF CUPEWfINO zap' +7� '�""" • " a` '
BUILDING DIVISION PERMIT co INk C)RMATIQN �:.
BUILDING ADDRESS: A+ PLUS CONSTRUCTION PERMITNO03110134
OWNERS NAME: PERMIT ISSUE DATE
.JNE: SANITARY N0. 7 CONTROL NO.
(408) 251-3733 1
ARCHITECT/ENGINEER: - BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
0 0 0 0
HOO LICENSED CONTRACTOR'S DECLARATION . . IObDeSCr
I hereby affirm that I am licensed under provisions of Chapter 9(commencing Job
tion 70)KE Ill, daion Sof the Bri'ne nd Professions Code.and my license is HNALED
in fail�f ryAadeffecs. -
Lqi L;censy.Clhss ,g71107 bio_ ADD 577 SQ. FT. -
^Fp lC CJOGE �S NOV 2004
e q t^,S ARCHITECT-S DEC TION
g a 1 understand my plana shell he used as ublic records
i
;oN
LicensedIbrofeaaiane' BUILDING
OWNER-BUILDER DECLARATION
C M 0 1 hcrcby affirm that 1 1. exempt from lW Contrn,Co :Any c Lew for the
which
..on. errs ft t 71DL4 Business and nve,Profession,Code:Any city m county
which reyuims n Permit re cnnawcl,alma ins for
demolish,rie a sig any atrunum
-zi that hpoor nslits cenedprolsumquirr Novisio antsof for Contrach ctor's
License
signed
ggss<
that me cing with Section
It)the provisions of the Conwness License Law(Chocter9 Sq.Ft. Floor Area ValU8h0❑
(comY I-� Meths is exemith Seetiomand)of Division M the Business Anand y
Cock)or
y Net he is campy taem(rom and Nc beer for be cts the exemption.Any violation of .�nart�uaxxrrr��h1a.�� pp
no,.Sectioh7031.5 byManfive hny undredapplicant
...($5,rmlo subjects the applicammacivil penalty of 3m11U0ah0eir00 OccupantC Type
not marc Nan five hundred dollen(5500). Y YP
❑Lea owner of the property,im is cmployces wird wages l Their sole eamperadon,
will do Pathe work.Co the s o Cont is not intended oro w do s not apply in
an Business
and property
ons Code:Thc ns themon,and
Law doe:not apply lf an owner of Required Inspections
propertywho buildsorimproveschicon,andwho does such work or
redthrough his
own employees,however,
Mebuilding
that such improvements arc not intended m leered fon oale,wn r-
however Ne building or den of pm,nl is that
within one year of completion,the owner-
builder will have the burden of proving Net he did not Wild or improve for puryoac of
ralcJ.
1,as owner of Ne property,am exclusively contracting with licensed contractors to
c nswct the project(Sec.7814,Business and Professions Code:)The Contractors Li.
cense law docs not apply to an owner ofproperty who Wilds or impor.Nemon,and -
who contracts for such projects with a contractor(s)licensed pursuant to Ne Contractor.
Littre Law.
❑l am exempt under Sec. _.B&P C for NO reason
Owner Date _
WORKER'S COMPENSATIONDECLARATION
I hereby affirm under Penalty or perjury one of the following declarations:
I have and will maintain a Cenifcate or Consent to self-Ina me for Worker's Compaq.
sation,as provided for by Section 3700 of Ne labor Cotic,for Ne performance of the
work for which this Permit IS Issued.
❑1 have And will maintain Workers Compensation Insurance,as required by Section
3700 of the Labor Code,for Ne performance of Ne work for which this permit is issued.
My Worker's Compensation Insurance carrier and Policy number art:
CA 'a,; %�-PE.r..' Polity A.: 5'30v"6 -
CERTIFICATEOF EM ROM WORKERS'
COMPENSATI RANCE
(This well need not W completed if the Permit is for one hundred dollam(SIWE
i or less.)
1 eerily Nat in the performance of Ne work for which this Permit is issued.1 shall not
employ any Nixon in any mannerso As to become subject o the Workers Compensation
Laws of California.Date
Applicant .
NOTICE TO APPLICANT:It.After making this Certificate of Exemption,you should
become subject to We Workers Compensation provisions of the labor Code,you must
.J O foMwith comply with such provisions or this permit shall he deemed mvoked. -
z r. CONSTRUCTION LENDING AGENCY
o-�.[-t Ihemb affirm that Mere is a construction]ending g a genet for the performance of
Clsthe work for which this permit Is issued(Sec.7097,CO,CJ
WIsntler'a Name
� Q
z Lender's Address
U Q 1 certify that I have read this application end soon that the show,informatloo is
IL.H correct.l agree to comply with all city and county ordinances and stem laws mooing to
OV building conswction.and hereby authorise repreentativea of this city to enter upon the
d above-mentioned property for inspection purposes.
(Wn)acme to save,indemnify and keexpatriatesu less the City of Cupertino aCaintat
tF-t to Iiabilitics,jud5mcam.costa and expatriatesm
s which may in anyway acce against amid Ciy
nsequenc
his
V z APPLICANTeUNDERSTANDSof the gnting OftAND WILL COMPLY WITH ALL NON-POINT Issued by: Date
SOURCE REGULATIONS.
/.7a —� > Re-roofs
umof Applioa. Conv.I., Dam
HAZARDOUS MATERIALS DISCLOSURE Type of Roof
Will Me applicant or future building occupant store or handle hazardous material
as defined by the Cupertino Municipal Code,Chapter 9.12.and Ne Health and Safety
Calc,Section 25532(a)? All roofs shall be inspected prior to any roofing material being installed.
❑Ye No
Will the applicant or future building occupant use equipment or devices which If a roof is installed without first obtaining an inspection,I agree to remove
hozamous air contaminants m dcfned by the Bay Arca Air Quality Management all new materials for Inspection.
District? -
❑Ycs QNu
I have mad the hazardous materials requirements under Chapter 6.95 of doe Califor-
niaHealth&SafelyCodc,Sodom 25505,25533 and 25534.1 understand thaz ift a Wilding
docs not currently hese a tenant Nal itis my responsibility to no c mcupant of the
myuimmcnta which must he tto.or lu steamer ofa CcnificateofOc xray. Signature of Applicant Date
All roof coverings to be Class"B"or better
O r or suthcrix,d agent Die — — —