04110162 CITY OF CUPERTINO
BUILDINGDIVISION PERMITCONTItACT,ORINF012MATIQN
BUILDING ADDRESS: DCMI PERMITNOO411O162
i39 RipaRWAY MR
ER'S NAME: PERMIT ISSUE DATE
NE: SANITARY NO. CONTROL NO.
ARCHITECDBNGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
to LICENSED CONTRACTOR'S DECLARATION- Job DeSCI'I
p��,. IL �N}ap 0 0
Ihemby ion7M)firmOat latefMe Bdunderpd Professions
hapter 9 Code.
Pgr-2](�. A ArW LED wifull(O nlgkpof Divtsian Sof the Buainruand Professium Cade,and mylicensc is BnO��'AVn1Y/(s�NN �Ppe
Llczr l and,rcea rfq/2241 STORAGE RM (EXCAVATION)
j License CI Lie.N
3 Dam o�`os�_Contractori.Y. T CONNECT CRAUL SPACE TO STORAGE
f ARCHITECTS DECLARATION
ndcn- sixund my Ph upublic m<nrds CONTRACTOR: DCMI FFR 2005
a-
e ¢c "'alt
m mortal
6 OWNER Bxe ER DECLARATION p n����
0 I hereby.(fate that 1 ore exempt s an the Cozens Co e:LicenseAny c Law for the np4M✓rl{I
O following reason.(Section 7031.5,5,Business end Improve,
de oli Code:Any city car county
3$
which mquinsnpermit re enmbealter.itforsuh Perlia care a sir any gnedalrumure
_Z NG
pdormits censed pursantto Me tbevision of for tach Permute Rkse Law antemcnl
p (that c.mmccin$wJPurwantatheomvislomofthe ofbeBuxmrindproflaw(Cmc)or Sq.Ft.Floor Area Valuation
z $ 'Mt As Is
xem wish Section7000)n0 the
Diasis f r M the sled Business and on.Any
Crvk)Or
e Natio ts exempt therefrom and the burs for the alleged exemption.Any violation of820000
Secnor noreMnfl.any doll..(Spermit mbJects the applicammecivil Penalty or APN Number Occupancy Type
nos mon Nan Rve hundred dollen(5500).
❑L u owner of the Pmpacium is u intended with wage u (Sm.
aW,Business
will Prodo fessions
and Nehe Contra not intended orofferedTonle(Sac.to an wneru
34241026 .
and Professions code:The Contractors Lkerw Law rima not apply m,n owner of 0 Required Inspections
propenywho Wilds mimpowes therem,and who does suchworkhimth
alforrough his
own employ=.provided that such improvements arenot intended oroffemd formic.If. _
however,the building or improvement is veld within ars year of completion,Ne owner.
builder wi0 ban the burden of proving Nat he did mt Wild or improve for Purpose of
ale.).
❑1,as owner of the prop,ny,em emlosinly converting with licensed mmuumn m
comtmct the project(Sec.]Oda,Business ad Pmfcuiona Cade:)The Contractor's Li.
cense law dma not apply An an owner of property who Wilda or improves tismon,and,
who contracts for such projects with s contrermr(U licensed pursuant to the Convector's
Um.I.W.
❑Iamuemptunder Sec .B&Pefarddsmssan
r Data
WORKER'S COMPENSATION DECLARATION
1 hereby affirm under penalty of perjury am of the following declarations:
I love and will maintain a Certificate of Consent W self-imus Lou Workers Cwnpery
urian,As provided for by Section 3700 of the labor Cade.for Ne pedommace of the
work for which this permit is issued.
❑I have and will maintain Worker's Compensation Insurance,as required by Section ,
7700 of the Labor Code,for Ne performance of me work fm which this Permit is Issued.
My Workers Carnperrat Insurance carrier and Policy number art:
Cartier. Policy No.:19.24V8/
C'RTIgCATEPFJ(EMPTION FROM WORKERS'
COMPENSATION INSURANCE
(This action read ms W completed irtbe permit Isfwonc humbeddallan($LOI)
or less.)
1 certify that in the pmr.hr arca of the work far which this Permit it Wood,I shall not
employ any Person in any manner an as an become subject in the Worker.'L'ompemaion
Laws of California.Data
Applicant
NOTICE TO APPLICANT:If,after making this Car incate of Eacmption.you should
become subject an the Worker's Compemation provisions of dm labor Cade,you must
�O mmwith comply with such pmvHina err this Permit shall W dcemW mooted. _
M CONSTRUCTION LENDING AGENCY
I hereby affirm that them Is e construction lending agency for Ne perform race of
x r the work fur which thls Permit Is iamd(Sec.303),Civ.C.)
36 Q Undoes Name
z Lcnd,es Address -
L)0 I m tify that I have read this applirnla.And sum Nu the above information is
comm.I agree to comply with all city and county ordinances and area laws raising to
0 building construction.and hereby authorize representatives of this city to caw upon the
4 abovomeuimcd Property far lupection rumposes.
(We)agree to an,indemnify and keep harmless the City of Cupcnino against
liabilities,judgments.cuts and expc•.-xi which may in any coy acrns agaims said City
in consequence of the
`)FFFiii APPLICA_VyJ UNDERSTANDSof thta remit.WIL OMPLY WITH ALL NON-POINT Issued by: Date
SOU �HaCULATION
01 t Re-roofs .
SignNote of ApplicaVContnemr am
HAZARDOA MATERIALS DISCLOSURE Type of Roof
Will the applicant or future building occupant came or handle baa dous material
a defined by the Cupertino Municipal Code.Chapter 9.12,and the Hcalib and Safety
'S
Sem as z'532 A)? All roofs shall be inspected prior to an roofing material being installed.
❑roe ON. P P Y g 8
Will the applicant or rumm building occupant use equipment or devices which If a roof is.installed without first obtaining an inspection,I agree to remove
7Dixtrim?
haurdaus air conmminants u dcRncd by Me Bay Area Air Quality Management all new materials for inspection.
❑Yes ❑No
I have mW Neb Anions materials requirements under Chalmr 6.95ofds Califor.
eath&SafetyCode,SaWou 25505,25533 am1253N.lar uchowd thatifthe Wilding
not currently have a soon.that it u y reap dhoity m notify tis occupant car thegm +which must bemet a oraccitifcato ofor upancy Signature of Applicant Date
s� /�6�r
own a attlorvedagen — All roof coverings to be Class"B"or better