04050048 (2) CITY OF CUPERTINO �-s �a"" a� �s y�
BUILDING DIVISION PERMIT W�1\r"CTOR,LNFII>Ri�V1ATIONr
BUILDING ADDRESS: STEPHEN M SMITH PERMIT 1.4050048
NTT`IT?PWq A17
OWNER'S NAME: PERMIT ISSUE DATE
STEPHEN M S
E: SANITARY NO. CONTROL NO.
ARCHITECDENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
0
u00 LICENSED CONTRACTOR'S DECLARATION
YwF 1 hereby affnm that I am limned under provisions of Chapter 9(commencing Job Description
SZwith Section 70W)of Division 3a1'the Business and Profeesium Code,and my license is
w
I.rens force and ercen. RE P I PE
4= License Class
nt- Dam cone Connector
ARCHITECTS DECLARATION
1 untlersanJ my pins shell W used as public records
its0 6
w Licensed Professional /
CgOWNER-BUILDER DECLARATION
<'A 1 hereby
affirm that 1 am exempt fuse dw Contractor's License Law for the
DO following reason.(Section 7031.5,Business and Professions Cade:Any city or county
a'm which requires a permit to construct,alter,improve,demolish,ar repair any Structure d
prior it)its issuance.also requires the applicant forsuch permit to file a sighed statement
SG that he is licensed pursuant to dm povisiunsof the Contactor.License Law(Chapter 9 Sq.Ft. Floor Area V tlOn
a t-$ (commencing with Section 7000)of Division 3 of the Businessand Professions Code)or
that he is exempt th unfram and the basis for We alleged exemption.Any violation of
Semon 7031.5 by any applicant for a permit subjects the applicant to a civil penalty ofgId�Ar7lbdd Occupancy Type
not mom than Eve hundred dollen($50)).
❑1.ne owner of the pmpeny,or my employees with wages u their sole compensation, '
will do the work,and the structure is not intended or offend for sale(Sm.7W,Business
and Professions Cc&:The Contractor's Llcerue Required Inspections law does not apply to an owner of q
property who builds or improves thereon,and who does such work himself ser through his
own employccs,provided that such Impromments arc not intended oroRered for sale.If.
however.the building or improvement is sold within one year of mmplction,the owner.
builder will ham the burden of roving that W did not Wild or improve for purpose of
sale.).
❑1,as owner of the property,am exclusively contracting with licensed contractors W
construct the project(Sec.7044.Business;and Professions Cade:)The Contractor's Lt.
cove law does not apply to an owner of property who Wilda at Improves thereon,and
who convects for much projects wish a contrecwr(s)licensed pursuant to the Contractor's
License law.
❑I am exempt under Sm ,B&PCT rth' museum
0 /r/ an. +w" •tom' Dam- - 7 4
WORK 'SCOMPENSATIOND ItAT10N
I hereby affirm under penalty of perjury oto oL\Blef/plowing declsntimor.
1 have and will maintain a Certificate of Consent m self-insure for Worker's Compen.
all..,n provided fm by Section 3700 of the labor Code,for the performed.of the
work for which this pewit is Issued,
❑1 have and will maintain Worker's Compensation Insurance,as required by Section '
3700 of the Labor Code,for me perfarmance of the work for which this Pewit is Wood,
My Worker's Compensation Insurance carrier and Policy number art:
Cartier. I Policy No.:
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(Thu sectio need Out W complewd lithe pewll Is Teton hundrcddullus($IN)
or In..)
I certify that in perfurmenee of the work for which this pewit u issued.label]not
employ any in any manner so as w becomesubject to the WarkuYCMwTom..
Laws o(Cali nia.Dow -
CEE TO APPLICANT.1f.after making this Certificate of Exemption,you should
subject w the Worker's Campcnmtion previsions of me labor Code,you must
.J,Z forthwith comply with such provinces or this permit shall W deemed revoked.
OCONSTRUCTION LENDING AGENCY
I hereby affirm that mere is a construction lending agency lot the Performance of
C'> the work for which this pewit is Wood(See.3097,Co.C.)
A Lender's Name
.7. z Lender'sAddress
(„)Q I anify that I have mad this application and seem that the above information is O
Hcowck I agree to comply with all city and county ordinances and sem laws relating to
Q V building convection,and hereby authorirn npromenutins of this city to enter upon the
L57 .hove-mentioned property for inspection purposes.
gy (We)agree to leve,indemnify and keep hawless the City of Cupnino against
liabilities,judgments,costs and expenses which may in any way accrue against said City (J
V z APPLICANTnsequenceUNDERSTANDSOf the granting ofthis AND WILL COMPLY WITH ALL N N-POINT Issued by:S44s-�tawDate
SOURCE RE L ONS.
ti^ S °t Re-roofs
nature of ApplimmuCcuormon, m
HAZARDOUS MATERIAL CLOSURE Type of Roof
Will the applicant or fawn building occupant more or handle infamous material
defined by the Cupertino Municipal Code,Chapwr 9.12,and the Health and Safety
Code.Second 255324)7 All roofs shall be inspected prior to any roofing material being installed.
❑Yes
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
,t hanodous air contaminants at defined by the Bay Area Air Quality Management all new materials for inspection.
DismicL9
Dyes elf.
I have mad the haxamtms mawrialsrequiremcnu under ,Chepter6.95 ofthe Califor-
niaHcal Sae,tyCode.Smrots25M5,25533 and25534.lundersmed mstiflW Wilding
does nor menrly ham a wnanl,mat it u my responsibility m nodfy the=upset of me
cnu whit must W mel prior wooancc ofa Cerifcjto of Occu enc Signature of Applicant Date
f,. •O'/A `� 5�7��� All roof coverings to be Class "B"or better
owner orowncr or t �— Dam g