04120059 CITY OFCUPERTINO ^� '
BUILDING DIVISION PERMIT CONTRACTQR INFORMATION
�bb3.�fv .w 3tpYeypp '42
BUILDING ADDRESS: PERMMNO.
04120059
OWNS S AME: PERMIT ISSUE DATE
NE:
SANITARY tdNfROL NO.
ARCHfIECT/ENGINEER:
BUILDING PERMIT INFO
' BLDG ELECT PLUMB MECH'
0
u00 LICENSED CONTRACTOR'S DECLARATION JobDescri tion
u F I ameby arms that I am IicemN under provisions of Chapter 9(commencing p
with Section 7")of Division 3 of the Business and Professions Code.and my license is
^?0; LmaneCl and effect. 2 SFDWL-2 STORY (3843 ' LIVING)
p ta Z License me Lic.N
contractor GARAGE 494 SQ. FT.
'-� A CHIT I DECLARATIp
�i I understand my plans Nall W head u public awards
JyU
3 G G Licensed Professional
3 OWNER-BUILDER DECLARATION
I I hereby affirm that I am exempt from the Contractor's License Law for[be
D O following reason.(Section RD 1.5,Business and Pmfiaions Cale:Any city or county
which mquircs o permit us construct,arm,.improve.demolish,or repair any suuclure
prior a)its resonance.also requires tM applicant for such permit to rile a signed statement
< that W is licensed pursuant to the provisions of the Contractor's license lew(CMpmr9 Sq.Ft.Floor Area Va]•_il7&t}nA000
x€S (commencing with Section 7000)or Division 3 of the Business and Profassions Code)or '7 /b
.� Nat he is exempt therefrom and the basis for IM alleged exemption.Any violation of
Section 7031.3 by any applicant for a permit subjects the applicant to a civil penally of APN Number Occupancy T
not more than Bn hundred dollen(SIM. P Y YPe
01,ummrofthepmpwy,mmyemploycawithwageuIMhxlecompenulion, 3571544.2-. 00
will do the work.and the machine is noantended in offered foreae,(Sec.700,4,Business / a' Required Inspections
and Professions Code:The Chastener License Law dons not apply b an owner of
pmpeny who builds orimpoves thereon,and whodeassuchworklumselfor through his
own employes,provided this such improvements sm col intended moffemd forsele.If.
however.the building or improvement¢sold within one yea of mmplarion,the owner-
builder will ban the burden of proving Nat M did not Wild or improve for purpose of
talc./.
+- ❑1,as owner ref the property,am exclusively concocting wide liaresed anuacnrs m
construct the project(Sec 7000,Business and Protections Cade:)TM Commcror's Li.
cane law dors not apply to an owner of pmpeny who Wilds or improves Income.and,
who contracts for such projects with a eonuactor(s)licensed pursuant in the Contractor's
License Law.
0 l am exempt under Sea ,B&P C fm this reason
sur Date
WORKER'S COMPENSATION DECLARATION - �7 ,pq g�
IMnd will mai under timidly of pajuryoee of lMhisure for Workers or R ry /ss\ f7 �{1�
IMnand will mainuina Cerafiale of Conxntnulf-insure for Warkcr's Compen- YUy1�NMta�/W((��4hi Ft4JI5p f�f /W%
ration,u provided for by Senior 3700 of IM Labor Code,for Ne performance of the
work for which this Permit is issued,
❑I ban and will maintain Warieri Compensation Insurance u required by Section 'f I III
3700 of the labor Code,for tM performance,of dee work for which this permit is issued. � �l L It
My Wmker's Compemadon Ire omarme carrier and Policy number am- {Iy'�3�y01 {tgp77 I{qty'' gyryff ��A7[�t(rypff �-s
Gamer:S�Policy No.RAel-0!21 � ct� 2lGa�tl e0 a
CERTIFIC OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(this section need not becomplemd if tbe Permit is forane hundred dollars(SIoo)
or hers.)
1 unary that in IM Performance of the work for which this permit is issued.l shall not
employ any person in any manner x as to become subject to the Workers'Compensation
Laws of California.Data
Applicant
NOTICE TO APPLICANT:If,after making this Ceniaau of Exemption,you should
become subject n the Workers Compensation provisions of the Lerner Cade,you most
.J ,z forthwith comply with such provisions or this Permit hall m decreed ranked.
zCONSTRUCTION LENDING AGENCY
f, IMreby aRrm Na comm is a conrmclinn lending agency far use performance of
C .�. the work fur which this permit is issued(Sex.3097,Civ.CJ
aQ Undies Name
.7 z Lender's Address
U C) 1 modify Na I have rad Nie application and sun that the a Wn information u
Ice, f' correct.1 agree to comply with all city and county ordinances and scale laws misting to
O V building construction,and hereby.udeorim representatives ofthis City to enter upon the
rty
rLQ above-mentioned tlpmpcst lrad expenses
which may
(We)agree to save,indemnify and keep harmless the City of Cupertino against
r V incoiaxecrue mcnapcoeuing expemsuwhich may in any way aamc against said City
V z A APPLICANT
of thegranting of this Permit.
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT Issued by: Date
SOURCE LATI > 9
r y/�
Sign ' ApplmanVConcrmtor f1-a Y aD'�' Re-roofs
HAZARDOUS MATIfRIOILS DISCLOSURE Type of Roof
Will the applicant or future Wilding occupant store or handle hvndous material
as defined by the Cupertino Municipal Code.Chapter 9.13.and the Health and Safety
I.Code.Oyes 35332(e)7 QNn All roofs shall be inspected prior to any roofing material being installed.
FWill the applicant or are building occupier am equipment or devices which If a roof is installed without first obtaining an inspection,I agree to remove
t n7,ardmm air contaminants as defined by IM Bay Area Air Quality Management - all new materials for inspection.
DiSca m?
❑Yes �No
1 have readtheha>a msmawrialsmquimmenuunder Chapur695ofthe Califon.
nu Heel"Safcry Cade.sections 35N1 X533 and 755th.l undersuM lhuiftlhe Wilding
arcs not currently ban a Ienul that it u my rapomibilry n notify Ile meopenl of Ne,
mment3.quimh must be m I prior w issuance of a Certificate of occupancy.
Signature of Applicant Date
CIamer m.awnmiaea again / Dau;
All roof coverings to be Class"B"or better
— G,