05050103 CITY OF CUPERTINO r *xassR ^'
BUILDING DIVISION PERMIT �,,CONTRACTOR.YNk.,O.r . ATION
BUILDING ADDRESS: PERMIT NOO 5 0 5 0103
100c;-7 CZ(-RNja 2114D
OWNER'S NAME: PERMIT ISSUE DATE
E: SANITARY 0. CONTROL NO.
ARCHITECTIENGINEER: BUILDING PERMRINFO
BLDG ELECT PLUMB MECH
LCM
O z LICENSED CONTRACTOR'S DECLARATION Job Descr,v'Io
1 herby affirm Wsl 1 am licensed under prova ons of Chapter 9 woncra Bing F Aefg D Q v ® O O
With Section 70BB)of Division 3 of the Business and Prefeallom Cade.and my license is �w\e,,®(/je®,L
In full in=and cRem.
5�z Llcenm Cl Lle.R INSTALL SKYLIT
=
Dan Contractor -
3 SOECLARATION CONTRACTOR: CALIFORNIA SKYLIGHTS
zqg
Lkense1 un onalYp all be used u it bit .__/ 9005
ItS
2woofiff
OWNER-BU DERDECL ATION 1/8 f' LIf,I��`�d�n
0 y I hereby alarm onn1 1 1. exempt from Ne Contractor's License Lew for the u I Nw®III V
ymD following reason(South 71I A. Business and . ons Code:Any city or county
u$� which requires a permit w construct,alar.Improve.demolish,m repair any structure
Fz5 prior m its issuance.also requirea the applicant for such permit w file a signed mlemen,
i�� that W k licensed pursuant in the provisions of the Conwamenes lat40j1c.LA- Sq. Ft. Floor Area Valua142
y� $ (commencing with Suwon 7000)of Division 3 of the Business and Professions COCA)or v�
.- that he is exempt menfrom and the bask for the alleged exemption.Any violation of
Section 7071.5 by any applicant for a permit subjects the Applicant o a civil penalty of APN Number Occupancy Type
not mom man five hundred dollars($500).
35709058 . 00
❑1,u owner of da pmpu,y,m my employees wW wages u Bak sok compevation,
and do mewank,and the he 0mr o me.Livens Low Cases
set A(Sec.]061,Budnw
and property
Code:The improves
an,License m,docs rot apply lf an owner of Required Inspections
own eny who s,Itch arimpeoaa thereon,and who dcesaah work or
or through his
hmcwr,lmeWil Wilding
or i that such improold witsmne year fc ma@m,for Ask.If. ..
builder ,me building mImprovementissoldwithinoroyear ofamovefortheowucr-
builder will how the burden of paving W,W did Inst build or improve for purpose of
ale.).
❑i,as owner of the property am exclusively contracting with licensed ccumacwn to
construct the project(See.7044,Business and Professions Code:)The Contractor's Li.
cense Law dans not pply In an owner of property who build.or Improves memos.and.
who contacts for such projects with a conuactar(Q licensed pursuant to me Contractor's
License Law,
l am exempt under See ,B A,P C fm this won
Owner Dow
WORKER'S COMPENSATION DECLARATION
I ameby affmn under penalty of perjury one of the fallowing dectsations:
'..and will maintain aCeNRale of Consent to self-insure fur Worker's Compen.
M'.As provided for by Sadon 3700.f the Labor Cade.for door performance of me
work for which this permit is mood.
❑1 have and will maintain Worker's Campenutlon Insurance,As requisd by Secdon
3700 of the labor Code,for the performance of we wart for which this permit k Issued.
My Worker's Compensation Issuance Carrier and Policy number are:
Carver. -J l/TJ6 ��,J� PoIIry No.: —0
CERTIFICATEOF APIION FROM WORKERS'
COMPENSATION INSURANCE
(Omkaec,ion need not bccomplewd ifthe permit is wronchundmd dollar($Ig)
or less.)
I certify that In the performance of the work for which this permit is issued.I hull am -
employ any person in any manner an As or become subject to the Worked Compensation
Laws of California.Dau
Applicant
NOTICE TO APPLICANT:Jr.alwr making this Ceeifcate of Exemption,you mould
became subject to the Worker's Compensation provisions of dw Laba Code,you most
Oforthwith comply with such provisions or this permit NN W lamed soaked. .,
zz CONSTRUCTION LENDING AGENCY
E4hereby affirm that then is a construction lending agency l'nr the performance of
7 the work fur which this permit is Issued(Sm.3097,Civ,C.)
QIAndue:Name
Z)Cl.z Leader's Address
U Q 1 certify that 1 have read this application and sum that the above information k '
ILI COMCL 1 agrec to comply with all city and county ordinances and sate laws slating to
ou building construction.and hereby authorize mmosenutives of wa city to saver upon the
[17 above-mentioned Property for Inspection Pugases
fy (We)agate in save.indemnify and kap h.rmku the City of Cupertino allows,
rA liabilities,judgments,cam and expenses which may in any w'ay Accrue against sold City
APPLICA ncc of ERSTANDS'AND WILL COM WITH ALL NON-POINT Issued by: Date
50 CATIONS.
�i Re-roofs
Signuure of APD ion ser ate
N RDOUS MA IAfS DISCLOSURE Type of Roof
WIII the aCsapplicant w future Wilding occupant team or handle Health and
As Mfincd by the Cupertino Municipal Code,Chapter 9,12.and the Health and Safety
Cade,Section 15531(a)7 All roofs shall be inspected prior to any roofing material being installed.
❑Yes Pw
Will dm applicant or future Wading occupant am equipment m devices which If a roof is installed without first obtaining an inspection,I agree to remove
hanrdous air contaminants As defined by the Bay Area Air Quality Management all new materials for inspection.
all
❑Yes a
I haw mW the huand ws mawrials requirements under Chapter 6.95 ofthe Califor.
nk Has["SafelYCode.Socacvu 25305,15533 and 25534.1 undcnund she if the Wilding
does act currtnBy hate wnant met Ire u my sapehe's, ty w aceupant of the
he
abcmetpriorwissuanceof maw ofOccu y Signature ofApplicant Date
ownrar.amarizeaagem sew All roof coverings to be Class "B"or better