NO PERMIT NUMBER CITY
BUILDING nrvlstoN CONTRACTOR INFORMATION:
BU11,101f hS.''. PERMIT NO.
3 S.c , f FgrZ nl A a
OWNER'BNAMF. APPLICATION SUI)DATE
)NE:: SANITARY NO. CONTROL NO.
7,wcowe
CIIITEC VENGINEEW BUILDING PERMIT INTO
TEMPORARY POWER BLDG ELECT' PLUMB MECN
LICLN t[muliNTRdCmR'S DECLARATION0Ihac7(XK)),,iIAby affil lu3oflneBo,une nrvisianxofCbCode9ndo,IrncingJO eserlpDon
� h Scedor,,.n cfvcl. nn3ofdm liusincd and Profession.CuJcandmyllucnxcn !lassandc0w[.Class [.it.p
L U Date Convaalar
HaFn ARCHR EM S DECLs,RA'I ION ,
1 understand my plans shall be used as public records
rc z o 0 Licensed Prnl'es,ionul
°ur•d OWNER-BUILDER DECLARATION
I hereby Dram that 1 am exempt from the Contracmi s License Law for the
C a Ibllowin,reason.(Senion 7031.5,Burson,anal Professions Ctd,Any it,nr caumy
e which requires a permit Ia a.wm,b aIle,improve.demolish,or repair any amemre
a3$ Flrion,Iit,ifeuancaAs)rennins the applicant for Inch permit to file a signed statement3
Jru[ cis liccnscd parevnmmtheprovishnxsnf the QonuectnAs Llcensa Law(Chana 9 Sq. Ft. IODr rest Valuation
(commencing with Section TXXR of Division 3 of the Business and Professions Cave)
or that he is exempt therefrom and the basis for the alleged exemption.Any violation
of Section 701.5 by uuy appliennl fur it permit subjcax floc appllcnm m a civil penally
of on more that,five nandred dollar.,fs5(X)1. - Ap304m e1 ROl16H EL CTRICAL Occupancy Typc
❑I.as owner of the pru,serly.or my employees with wages as lhcir sale compensation,
will Jo the work,and the s[memre is not ialntded nr offered for safe(Sec.7044•
Business and Prom„inn.Cede The Cn draetn,,License Law encs tan appl,to an Required Inspections
orr of properly Who builds or improves thereon.and who dues such work himself
Ihiongh his own etuploycex.pn;,iJed that Bach hnpu,vementx tire on intended or
offered for sale.If,however,the building or improve ncto is.sold within one year of
completion,the owncrhuilder will have the burden ofpraving that he did Bol Wild or
npnwc I iaptopnscol salol.
❑L as owncr of the property,am exclusively cnnlructing with licensed contractors o, '
taxon the project(Ser.7144.Business and Prole—r as Code.)The Cnmraeut's
Lleenw Law does nal ttpply[o on owner o1',..sped,who build,nr hu,wcx thereon.
and who contracts for such reopen¢with o conlmclort,)licensed per uant ,the
Coumaoev License law.
❑I nal cxcmpt ander See. .II&P C tot this rea,n
Owner Date
WORKER'S COMPENSATION DECI.ARA9 ION `
Iseof rm under penally of perjury one of the following deemmtiome w\
I Iave rand will maintain a Cefilleme of Consent ,sell insure Ibr Worker's
omgemn[ion, a, provided for by Sec,ion 3704 If the Labor Col, for the
1 prbr.ntancc of the work for which this pem,it is issued.' -
❑I have and will maintain W'orker's Compensation Insurance,as required by Section
37(X)of the Lobor Code,for the performance of the work for which this permit is
sued.My W..Mr's Contpalanion Ituuranee carrier and Polley nomher arm '
Cartier: Policy No.: ,
C12RI IICATION OI'EXEMPTION FROM WORKERS'
COMI'LNSAI']ON INSURANCE -
(This section need Bol W completed if the perrnit is lit one hundred dollars
(S l W)or less.) - s
12erify that in the ptdom once of the work for which this permit is issued,I
shall nm auploy any lie ra,n in any ,,I ler nu ax m become subject w[he W..Ives'
C..... satins Laws of Calili,rma.Dam
Applicant
NOTICE TO APPLICANT':IL Lifter making This Certificate of Exemption,you should
recount,ahjcct to the Worker's Contpcusadon pmvisinns of the Edo,Coda yon tow[
Q forthwith comply with such provisiorm
ns of this peit,hall W demned revoked.
ZOVi CONS'I'RUCTION LEN DI NO AGENCY
I I hereby affirm that There is a connlmetion lending agency for the perfom,ance
W of the work for which this permit is issued(Sec.3097.Civ,C.)
Q Lender:,Nutue
7 Lender i Addoss
V 0 1 cer ity that I have road this xpplicntion and sane that the above infurmation is
Ls. ;: comm.I agree to eonlply with all dly and musty ordlnattocs and state law,relating
0 U to huilding comwetion.and hereby authorize mpmmntativex nfthis city In enter upon
the aboven volumed p,,,,.y for in,,,Iicn purpa,cs.
(We);”"In savo.indenmilyand keep bafudexs the Cry In Cupertino ageinst
N liabilities,judgments,costs and expenses which may in any way accrue against said
V Z City in consequence of the granting of this permit.
r
SOURCE
ANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT Issued by: o 'EJ Date
Signature of AppLeaNContractor Date Re-roofs
I IAiiARDOUS MATERIA S DISCLOSURE
Will the applicant or future building occupant stole or handle haea,dou,material Type of Roof
as dc0nef by the Cupcmino Municipal Code,Chapter 9.12 and the flatllh and Safety
Code,Section 2553200!
❑Yes 0 N All roofs shall be inspected prior to any rooting material being installed.
Wits nmapphri ,it nttmebtdd'mgneonpanttr,e u pouvitordeviceawhlvh If a roof is installed without first obtaining an inspection, 1 agree to remove
emit hmurdaos air mnmtnhmrd,as defined by the Bay Mea Air Quality Managctnen[
ixlricn all new materials for inspection. Applicant understands and will comply with
71 Yes El Nu all non-point Source regulations.
I have read the hazardous materials requirements under Chapter 6.95 of the
Califnrnit hleahh R Satay Code.seen 1,25505,25533 and 25.5341 todmtanJthat
n the building does not cno,ody haven[amnl.[het it ix my responsi hi lily m notify the
ocupan,of the regaimmems which mus,be met prior m issuance of a Cerificme of
ccupancy.
Signature of Applicant Date
Owner or authorized ages[ Date All roof coverings to be Class "B"or better
OFFICE