04080252 CITY OF CUPERTINO R
BUILDING DIVISION PEMIT G`C1NRtiTQI2 'N' " M;1fi.TU
BUILDING ADDRESS: PL-RMI I NO.
STEVE NAN CONSTRUCTION 04080252
PERMITrxrBDATB
E, SANITARY OL N0,
ARCHITECT/ENGINEER: (408) 203-2923
BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
0 0 0 0
yop LICENSED CONTRACTOR'S DECLARATION
1 hcmby afrrm that 1 am 11rd unJer p u ns of Chaplor 9(Commentlng Job Description
wiNS on )of Division3ofNe Businaua P aaiom Code.mdmyliCm i%
^=y in full rad effect. •^
5z Data = REVISION--IN HOUSE USE ONLY
Data `-- Conuukr
ARCHITECTS DECL�N NO NEW PERMIT ISSUED/ ORIG. #04050027
�i Iund.4?-,
landmy plansshall he used u public=CurN
0�v
o�S Licensed Professional n
23 at18.OWNER-BUILDER DECLARATION
0 I hmehy.mere that 11. exempt from Ne Ce.tmmm'a License Law for the
20 following mass..(Section 7031.3,Business and improve.
d abli Cmk:Any city or county
pd.t requires,.corm.re cnrmuuO,alma improve,h permit t m repair any mumum
priorroiuisaumwaaBant In Me prevision
of for eacCompactor'rLicenso filo a sLaw(utemem
zitsNal me cingwiitpumuanttotheofDiviomofthe eBosomr'aLironuLew(Chepmr9 Sq.Ft.Floor Area `� Valuation
that(coW is
with thourion 70n d M basis
r of Me al eged csaand Proon.Any
violation;Code)or v $Q
$ Net he V exempt thmefmm and the bmu for Ne tllegctl Gumption.Any viole�on of
Section 7031.3 by any applicant for a permit subjects the applicant to a civil Penalty of APN Number Occupancy e
not more Nan Eve hundred dollars(M). P Y •T7 P
❑I,as owner of the pmperty.or my employees with wages as their sole compensation,
will Jo Ne work,and Ne structure is Bart intended or offered for sale(Sec.7(344,Business
and Professions Code:The ContracmYs License Law dose not apply to an owner of Required Inspections
property who build,or ire proves Herron,end who does such workbimul f or through his
own employees.provided that such Improvements are not intended oroRered for sale.If,
however,the building or improvement is mid within one year of completion,the owner.
builder will have the burden of proving Nu M did not build or improve for purpose of
sal..).
❑1,as Owner of the property,am exclusively contracting with licensed common to
construct the project(Sec.7044,Business and Professions Cade:)The Conuacmrh U.
cove law does not apply as an owner of property who builds or improves thereon,and
who contracts for such pmjecu with a ctoddcm4a)licensed pursuant to Ne Contracte.
License Law.
❑I sm exempt under Sec. .B k P C for dos reason
Owner Data
WORKER'S COMPENSATION DECLARATION
I hereby affirm under penally of perjury one of Joe following declarations:
have and will maintain aCerOEcam of Consenuo self-insum for WorkeraCompen-
tion,as provided for by Suedon 3700 of Ne Ube,Code,for Ne performmm of Ne
.,it forwhieh this permit is isaved.
❑I have and will maintain Workers Compensation Insurance,as required by Section
37M of the Labor Code,for the performance Often,work for which this permit is Issued.
er's, o ape aortas Inaunnc artier and Policy urrybe� -
Ca r.
Policy FROM
CER KATE 0•COMPENSATION
EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(Theasetion=ad notWcomplekJ if Ne permit is forone hundeeddollam($IOIB
.,[.a$.)
I certify that in to performance of Ne work for which this permit is issued.l shall not
employ any person in any mannerm ss an become subject to the Workers Compensation
Law.of California.Dam
Applicant
NOTICE TO APPLICANT:If,alter making this Certificate of Exemption,you should
become subject to the Worker',Comp dammm provisions of in.labor Code.you must
.'O forthwith comply with such provisions or this permit shall be deemed revoked.
„z,�n CONSTRUCTION LENDING AGENCY
[r I hereby affirm that More ia.consraclion lending agency terhe performance of
!Xdo,work fur which this permit is issued(Sce.3097,Ci,C.)
Q Lender's None
.7. z Lender's Address
V C) I certify that 1 have read this application and auk that the above information is
{7. F correct.1 agree to comply with all city and county ordinancea and state laws minting to
0U building construction.and hereby authorize mpmumutires of this city to enter upon the
�a above-mentioned property for inspection purposes.
(We)agree to save,indemnify and keep harmless the City of Cuperimo against
rf"i In liabilities,judgments,costs and expenaas which may in my way acme egainatsaid City
(„)7 in consequencc of the granting of this permit.
'7 LICANT UNDERSTANDS ND WILL CO PLY WI AL N-POINT Issued by: Date
RCE REG TION .
Re-roofs
i m of Applica t/Contmcmr Date
HAZARDOUS MATERIALS DISCLOSURE Type of Roof
Will the applicant or future building occupant rare or handle ha udous material
as defined by the Cupenin a Ideal Code,Chapter 9.13,and Ne Health and Safely
Code,Section M533(an All roofs shall be inspected prior to any roofingmaterial being installe
❑Yes No
Will the applicant fut re building occupant use equipment or devices which If a roof is installed without first obtaining an inspection,I agree to remove
I hazardous air contaminants defined by the Bay Aka Air Quality Management all new materials for inspection.
trim?
❑Ycs
I have.dNe s krialare'murbnuu der .Chapkr693of Nc Califory
ria Health&SafclyCodc,Scctiom3 ,35533 anJ 35 .I matimund thatifthc Wilding
does nal morenlly haw a tenor I it u y reap. ilily m oddly the occupant of the
mqu' mawhi a ,prsar d roc "ca"nwc9 rev.- Signature of Applicant Date
o
dr Authorized agent Date All roof coverings to be Crass"B"or better