05030101 CITY OF CUPERTINOT'
BUILDING DIVISION PERMIT CONTRACTOI2IN>�;�OMA'I'IOI�
BUILDING ADDRESS: PERMIT"0 5 0 3 0101
OW NER'S NAME: PERMIT ISSUE DATE
NE: SANITARY 0. CONTROL NO.
ARCHITECT/ENGINEER: BUILDING PERMITINFO
BLDG ELECT PLUMB' MECH
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+�OpZ LICENSED CONTRACrOB'S DECLARATION Job Description
1 Wmby aRbm mat 1 am licensed under provisions of Chapter 9(commencing P
wW Sermon 70110)of Division 3 of the Business aha Profceelum Code.and my license is
^L se m Tull ense Cl and art 1
5 z LianeaCh Lk.g fia'ro�4-g ADD 189 . 12 (MS BED & BATH)
c�� Dam j/JI2�Contractor c Gv Y /J
-/ ' - ARCHITECTS DECLARATION CONTRACTOR: DUC CNEUYEN �
y 1 undersand my plans shall bo used u public meards
u,
Licensed Professional /
o Oat I am exempt
from
mDECLARATION l/
0 0 1 masa .(nese on 11. esempt Gum 0te Cankas Co e:A License Law for the may. p��
p m following mason.(Section 71D L5,Business and w.chrism Cad,:Any city structure
n zoos$ which requires a permit In ennewcL alter.improv,demo ii t ore sigmy umment // n b p d
'y^ PHormsl iensMe.a4antto the the
ovisioc of for suchpctise torileLaw( ha mem
thmboisliccnwipSecantrothcofDivWonfthe Conoic mdefmia Chapter9 Sq.F[. Floor Area v V31110000
B (cammen,exam
iN6ecdose,Add)th Danksfr of meeged exe pt Professions Code)or
.. Net he 4 exempt them(ram and 0e banks for me alleged exemption.Any viohdan of �•."''v^ f���` '���
Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of APN Number Occu ane `fy �z
oaf mote Nan Bw hundred dollar($300). P y L'Pe
❑i,uownerofthepmpeny,amyemployeowM.rAudeGmkcompewdon, 35613011 . 00
will do the work,and meaductuu is not Inteoded oroQmed foram(Sec.7044,Business
sod PaRssimu Code:The Conuum cter's Lt.law danot apply in an owner of Required Inspections
property who builds or Improwa mere on,a nd who does such work himsel f or through his
own emplayms,pmvided that such Improwmentsam notinended arortered f"sale.If.
hmvevea Ne Wilding or improwmenf is sold within one year of completion.the owner.
builder will have the burden of proving that M did Out Wild or improve for purpose of
alt.).
[11.as owner of the linearly.am udwivcly conducting wide licensed anvacmrs in
construct the project(Sec.7044,Business and Professions Cade:)The Contneter's L4
came law does not apply m an owner of property who builds or improv maser,and
who contracts for such pmjecu with a mnusctolp)Iimage d PurcanIto du Condacdor's
Lice.Law.
❑l am exempt under See. ,B A,P C for this reason
Owner Dau
WORKERS COMPENSATION DECLARATION
1 hereby afnnn under penalty of perjury one of the following declarations:
1 haw and will maintain•Ceninate of Consent to selGinmm far Worker's Compere
sultan.As provided for by Section 3700 of the Lab"Cade,for me performance of me
work for which this permit is issued.
❑I have and will maintain Wark,r's Compensation Insurance,as required by Section
3700 of me Leder Code,f"On performance of dee work for which this Permit is Wucd.
My Workcrl C mpye�u0an 1"nrneG armee and Policynumber ae:
Cartier. /L Polity 3
CERTIFICATED EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(Thu section need rat bocompleud Ifde permit Is foram hundred dollar(SIU)
or less.)
1 unify that in the purarmaxe of me work fur which this Permit is Wood.I shell not
employ any peran in any manner an u m become subject to the Workcri Compcnssdon
Laws of California.Dae
Applicant
NOTICE TO APPLICANT:If,armr making this Cer meek of Exemption,you should
become suncel to the Worker's Compensation provisions of than Labor Code,you must
.J O forthwith comply with such provisions"this permit Nall lac Accrued uvaked. ,.
r CONSTRUCTION LENDING AGENCY
f'e I Wuby aRrtm that mer is consuucdnn undingageney for the Performance of
the work for which this Permit Is Wood(Sec.3097,Civ.C.)
aQ Lcder's Name
O Z Lender's Addriss
U O 1 ardly that 1 haw mad this application and sum that the above information is
Iy F cermet 1 agree m comply with ail city and county ordinances and sum laws muting in
O Wilding construction,and hateby aumodu u
ansenuva tiof deisaity to cnmr upon me
�4 ahow-mendimed Property for inspection purposes
(We)agree In live,sMcmnify and keep h kss me City of Cupertino aftti tet
af'i y
liabilities,Judgments,e"u and expenses which may in any way accme Madan aid City
U In consequence of the Stenting of this Pmmik
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT Issued by: Date
SOU CE REGULATIONS.
C �� �O Re-roofs
Stimulate of ApplicanXI te�^�r Dau
HAZARDOUS MATERIALS DISCLOSURE Type of Roof
Will the applicant or room building occupant some,or handle haafdous material
M dermad by the Cupertino Municipal Code.Chapter 9.17,and the Health and Safety
Code.Scadan7S532fa)7 All roofs shall be inspected prior to any roofing material being installed.
❑Yes UA.
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
it thamdnus air anuminanu As defined by the Bay Area Air Quality Management
Dislrin7 all new materials for inspection.
❑Yee aNu
1 haw mad the haaNnus mateda4 mquimmenu under Chaper 6.95 of the Califon
.is Health A,SaletyCode,Sectio"25505.23333 end 25334.I undenund thud if the Wilding
does not eunemly how a knent that it is my rempo"ihility m notify de"eupant of the
rquiromenu which mug W met poor a issuance of a Ceninum of Occupancy. Signature of Applicant Date
O
Owner or authorized agent te All roof coverings to be Class"B"or better
v