03020067 C TY OF CUPERTINO _ ='*^ 's a'¢
Bliit.nlNc DrvIs1oN PERMIT u,CUNTRACTQR I,NFUTtMAmTON ,a#
BUILDING ADDRESS: PERMIT NO.
:R'S NAME: APPLICATIO
NE: SANITARY N-0 - CONTROL NO.
ARCHITECT/ENGINEER: BUILDING PERMIT INFO
p BLDG ELECT PLUMB MECH
z LICENSED CONTRACTOR'S DECLARATION
Ihereby affon that l am licensed under provisions M Chapter 9(commencing Job Description -
withSmfim7 Onf Diviaivn3of Ne Busincysend Prufgainns CoM,end myliccnrc is
in full fireAgpBd�feffoct.
'qg Lianas] Ls.N TEMPORARY POWER -0
Comneng
CHIE
ATIiIundcnJ my piensc' Tic
MAR 14
kwLkenseJPnfeuionel 7003
O OWNER-BUILDER DECLARATION
f I hereby affirm that 1 am exempt from the Contractors License Law for the BUILDING
�I, hlYkll''-
r,ip O following mason.(Secfiun 7)31.5,Business and Professions Code:Any city or county N • g•�i7
which requires a Permit to cngwcL after.improve,demolLah.at repair any structure
ZSa prior to its issuance,also requires the applicant for such permit o file a signed surement
C that he is licensed pursuant o the provisions of the Controqur's License Law(Chapter 9 Sq. Ft.Floor Area �I 100
$ (commencing with Section 7000)of Division 3 of the Business and Profcuions Code)or
that he is exempt therefrom and the light for the alleged exemption.Any violation of
Sermon 7031.5 by any applicant for a permit subjects the applicant o a civil penalty of
net more than RK hundred dollen($300). 3 00 Occupancy Type
❑I,u owner of the property,or my employees with wages as their sole compensation,
will do the wok,and the summure is not intended or ofemd for.1.(S..7W.Business 103 - UFER
and Professing Cade:The ConBectora License Law does not apply m an owner of Required Inspections
r, property who builds or improves thereon,and who doessuch work himselfar through his 304 ROUGH ELECTRICAL
aown employees,provided that such improvements are not Intended rroRered forale.If.
h osewr,the building or improvement is sold within one year of completion,the owner-
Wilder will have the burden of proving that be did our build or improve for purpose of
fir sale.).
❑1,as owner of the property,em exclusively contracting with licensed contractors to
1 consumer the project(Sec.7044,Business and Professions Cade:)The Contractors Li.
cage taw dom not apply on an owner of property who builds or improve thereon,and �aD
3 who contracts for such projects with a contractor(s)licensed pursuant to Convenors
Y License Law.
g I am exempt
tt]under Sm. / ,B A P C for this mason _
1,1$AAR Q'[j i ;'f /0
03
WO ER'S COMPENSATION DECLARATI
1 hereby alarm under pcnevy of perjury one of the following decluationic
Ihaveand will maintain a Certificate of Consent to self-insun for Workeb Compete
goon,u provided for by Section 3]00 of Ne labor Code,for Ne Performance of the -
work(or which Nis permit is issued. .
❑I hese and will maintain Workers Compensation Igurance,as required by Section
37000fdd Llhor Code,for the performance of the work for which this Permit is Word.
My Wmkera Compensation Insurance carrier and Policy nu�nie,.o:
ori : : _
CERTIFICATE OF E(EMPr1FROM WORKERS'
COMPENSATION INSURANCE
(Thb scnion necJ nor be cnmplcteJif rhe permitbfnrnnc huntlmd dollen(Slop
or less)
1 cenify the inth rformace of the work for which Nis permit u issued,I shall not
employ any pemme in manneryr/sto.�cpgte mbjecun the Workers Compensation
Lewsor California to Y!A' �o,�LL
AppB��p�)1� 4,lc f ��
NOf147 UP0 APPLICANT:IL after making this Ccnifice¢ cmx�ou should -
become subject to the Worker's Compensation provisions of the Labor Code,you must
.J'z forthwith comply with such provisions or this permit shall ha deemed revoked.
Z O CONSTRUCTION LENDING AGENCY
[—t I hereby affirm that there its construction lending agency for the perfmmance of
(YiNe work for which this permit is issued(Sec.3097,Cl,C.)
Q Lender's Name
=,z Lenders Address
V Q 1 cenify Nal 1 haw read this application and state that the above information is
Wcorrect,l agree to comply with all city and county ordinances and State laws mhting 10
DU building construction,and hereby authorise representatives of this city to enter upon the
W aMm-nentioned property for inspection purposes.
LL (We)agree to save.indemnify and keep homeless the City of Cupertino against
W liabilities,judgments,costs and expenses which may in any way acme against aid City /
V APPLICANTeUNDEof the RSTANDS ArantiofrND WILL COMPLY WITH ALL NON-POINT Issued by: Date l
SOURCE REGULATIONS,
A " Re-roofs
s'"rte not Appli HAZARDOUS
Dare
RDOO US MATERIALS DISCLOSURE Type of Roof-
I`
Will the applicant or future building tem,4m nor,our bri hacandous material
defined by the Cupertino Municipal Code,Chapter 9.17,and the Health and Safety _
.Section 2553r(e)'t
❑Yg AN. All roofs shall be inspected prior to any roofing material being installed.
Will the applicant or future buildingoccupanl use equipment ordeviaa which If a roof is installed without first obtaining an inspection,I agree to remove
7nia
hagmous air contaminants a defined by the Bay Area Air Quality Management all new materials for inspection.
Yes �t NmI haw read the hammnus materials requirements under Chapter 6.95 of the Califonealth&Safety Code,Sections 755)5,25533 and 35534.1 undemtenJ that if the building
not currently haw a toner,that II ht my responsibility te notify IM occupant of rite
rements which mug)e met pdortuissuanee ma Cc ' ceteor a 03 cy. Signature of Applicant Date
°4 %( R �"" All roof coverings to be Class"B" or better '
weer sir eurhomeJ agent Dam