05020092 CITY OF CUPERTINO r �x'�sa�s txd-n:14 .£ sx i
BUILDING DIVISION PERMIT C� ICTUR,Y1vI I]ILYVIATI� X16
BUILDING ADDRESS: PERMIT N.05020092 5020092
27E 2RPMR4];r6P'
OWNER'S NAME: PERMITISSUEDATE
SANITARY OL NO.
ARCHITECT/ENGINEER: BUILDING PERMIT INFO
BLDG= PLUMS MECH
t� 0
1 o o LICENSED CONTRACTOR'S DECLARATION
Its
rA i 1 hereby 0)of Mod I am licensed under and
Phires of men Code. 9(cemmcn ig is b DescriptionAi with Sudan 70W)of Division Sof tine Bugneuand Professiuw Code,and my Iicene k
in full fora and effect s E
ZnZ License Class Lk.0 ADD/REMODEL 615 II�1115 1111�� ++/LIVING
Dam ARCHITECfSConI�ECLARATION OFFICE/DINING
? 1 understand my plans shall Use wctl as public meet& 20
05
3 LKcnmd Pw(csdocal
Oat I am exempt I DECLARATION ��P I'�
0 1 hereby maga .(Seco that 11. exempt from the Cantracmes k:A License taw for tine
d O O whicfollowing acquires
(Swoon 7(D1.5,Business and PwlGsimu COdc:Any tiny or rouury
u�$ which I%issu r permit re requires
sto aiteaimprove,tleermitt or repair ed atromuro
pdarmiu iuuewa.tlsumqulmuMisions of for ach Permit OlcuLaw(suumcm -
F`�
we,huBeewedpueaamroNe pwvieloivaf the Gonuacwr'a LiwnelaW(Code)9 Sq. Ft. Floor Area ValUal 000
(commencing with Section 7Un d M Division 3 of the alleged
Business and Profeuiaes Cade)w 4
�3$ the,he"Is exempt therefrom and tine buil for tha atlugctl exemption.My violation of
Section 7031.5 by any applicant far a permit abjecu dm applicant at a civil penalty of APN Number Occupancy��7y•
nor mom Nlaw w hundred dollars($50D).
P y '7(�
❑1,as owner ofthe properly,or my employees with wages as thick sale compensation. 36212020 . 00
will do the work,and the auctwc is Out lnmM d.raQemd Woods(Sec.706/,Budrcsa Required Inspections
and Projections Cade:The Coruscates Licence Law does act apply w e an owner of q p
property who builds or improve Nereen.end who does such work himself or through his
awn employers.provided that such improvements arc not Intended wormed fatsak.if.
however,the building or inprowment is said within ane yea of cempwilon,the owner.
builder will hew the burden of proving Nat he did ver build or improve for purpose of
"IC.L
❑I.as owner of the property,am exclusively contracting with licensed contractors on
construct the project(Sec.76W,Business and Pro iom Code:)The Communes Li.
cenae Law does not w an awoer of pat .who builds as improves theean,and
who wntrecu for such projects with a eon at medimnwrte Ne .=ie.
License Law.
❑lam exempt undo Sec .11 PCfoe umuon 6
Owner D,e Or
W COMP S NDECLARATION
I heroby air..under penaltyo ped'ayrwofilefollowingdedantiwn:
arc and will maintain aCenificmoo(Canacnr to elhlnsum fat Workerl Compcm
tarM..
u provided for by Section 3700 of the Labor Cade,for the performance of the
work for which this permit is issued.
❑1 have and will maintain Wwkces Compensation Insurance.u required by Section
3700 of the Latour Coca,fat the performance of the wart for which this Permit is lune&
My Workees Compewation Insannce carrier and Policy number ate:
Cartier, Policy No.: _
CERTIFICATE OF EKEM MON FROM WORKERS'
COMPENSATION INSURANCE
(7Tlssectio,wed course completed if suit is forage hundreddmllan(SIM)
or less)
I unify the,in the parfarmanec Of the work forhitch this Permit u issued,I Mall not
employ any person in any mwwrsa uwbecom ubjwtn the WOrken'Cwnpenuron
Law of California.Dau
Applicant
NOTICE TO APPLICANT. a Inirinte of Exemption,you aboard
become subject w the wohees Compcnsa% vngmts of the talar Cade,you muse
.J O fOMM
with comply with such provisions or this permit all bm
e doomed ukcd. .,
zt"t CONSTRUCTION LENDING AGENCY
1 heroby allirm Nn Nee is a wextraction kndins agency far Use perfonnmw of
Ne work for which Nis permit ts Issued(Sec.3097,Civ.C.)
Q Lenders Name
z
Locators Acidmu
U 1 certify that 1 have mad this application and sum that LOU,hove information is '
IL CO MCL I agree at Comply with all city and county ordimsees and sum lawn mural no
C) Wilding contraction,and hereby authorise represenudwn of this city n enter open the
�.t Lk7 above-mentioned property,for im"Undan purlwses.
4 (We)agree to save,indemnify and keep harmk City of Cupcnino against
F V) liabilities,judgments,cora and expenses
whic
UNDERSTANDS Ah may in y my sera gtlmt said City
in U 7a APPLLICANT menco of to RSfANning of nND WILL COMPLY ALL NON-POINT Issued by: Date
SOURCE REGULATIONS. /
r Re-roofs
Signature of Applian✓Consmtw Dau
HAZARDOUS MATERIALS DISCLOSURE Type of Roof
Will the applicant w future building Occupant store or handle huudous materia
as defined by the Cupertino Municipal Code,Chapter 9.12,and the Health and Safety
Code,Swoon 25532nd? All roofs shall be inspected prior to any roofing material being installed.
[:]YG
Will ft applicant or future building occupant tae equipment or devices which If a roof is installed without first obtaining an inspection,I agree to remove
ayssdous air Cwwninants u dcrned by the Bay Area Air Quality Management all new materials for inspection.
R ,L
*
❑Yes t11^V"
I have mW the hvankns mauriauroquiroments under Chapter 6.95 of the Calif.u.
nulwa1th6SmctyCodc,Swtiam 25505,M3and 25574.1 undcntand tuifthc building
does not currently how•tenan4 this it ihiliry u notify the Occupant of the
requimments which mug W mat prior w UgMxroe or, dwitw aroxw a. —Signature of Applicant Date
Owwrwawnan ,gen; F77tr All roof coverings to be Class"B"or better