03110145 CITY OF CUPERTINO •" 7777777777--- ".QC,,
BUILDING DIVISION PERMIT C0NTjUCTOR INFORMATION u
BUILDING ADDRESS: RICH BATSFORD PERMrr NO 03110145
NER'S NAME: PERMIT L6UE DATE
RICH BA
ONE: SANRARY NO. CONTROL NO.
ARCHITECT/ENGINEER: BUILDING PERMIT INFO
BLDG EIECi PLUMB MECH
0 0 0 0
400 LICENSED CONTRACTOR'S DECLARATION
1loreby&from that I am licensed under provisions of Chapter 9(commencing lob Description
ith Satim7(k1K)mf DiA3ion3ofthe Buri and Nollum us Code,and my license is
rt'1a Lion e Pa eBa � ADD 800 SQ. FT. q>�a� fg qq
;� Liad— (i NglC yg{ D
Cmntn r L IfYg$9 SI�y(.rlq��i
iia at( y p1a R I G usS� cords
g Li Jmfcuio 1
OWNER- ILDER DECLARATION �. .
.�<I 1 hereby affirm Nat 1 am meopt form the Commeda's License law for the
00 fallowing mosed.(section 7031.5.Business and Rrfestions Code:Any city nr county
y g E! which requires a permit to construct,alter,improve,demolish,nr repair any structure ARM �2
prior to its issuance.also requires the applicant for such permit to file a signed statement
7,C NatWisdemand pursuant tothe provisions ofNeConuxwfsLiam¢Law(Chaptn9 Sq.F[. Floor Area b' Valuation
tc (commencing with Section 7000)of Division 3 of the Business and Pmfeasions Cmi or �I "^'A
in $ that k is exempt therefrom and the basis for the alleged exemption.Any violation of
Section 7031.5 by any applicant for a permit subjects Ne applicant m a civil penalty of 3 5WBI]rU"er0 0 Occupancy 1
nos more then five hundred donors(5500). P Y J'Pe
L as owns of the property,or my employes with wags as their mle Compensation,
will do Newark and Ne swam is notimmnded oraRemd fmsak(Sec.7O .Business
and Prormooru Code:The Cuntracmr's License Law dors not apply re in owner of Required Inspections
propenywho Wilds orimproves thereon.and who timsuch work himsNor through his
ownemployas,provided that such improvements art notinrcMM esoRarsd for We.M
however.the Wilding or improvement is sold within..year of completion,the Owner.
Wilder will have the turden of proving that M did not Wild or improve for ndpose of
.In I.
❑1.u owner of the property,am exclusively contracting with licensed contractors to
construct use project(Sue.701(Business and Profusions Cade:)the Conuacter's Li
cense law does not apply m an owner of property who Wilds or improve thereon.and
who mount for such pmjecu with a coutnetor(s)licensed pursuant in the Contractor's
Liaue Law.
❑1 am exempt under Sec. ,B k P C for this moon
Date
WORKER'S COMPENSATON OECIARADow
1 hereby afro under penalty of perjury one of Nc following decimations:
❑1 haw and will maintain a Certificate of Consent to alf-insure for Workcfe Compcm
ation,as provided for by Section 37W of the Labor Code.for the performance of the
work for which this permit is issued
❑1 have and will mountain Worker's Compensation Insurance,as required by Section
37W of the labor Code,for the performana or the.,it for which this permit is issued.
My Work Compensation In m¢ cam"and policy number are: 1G 666 w�
q mer. Poli d �/� /D / Ltd
ERTIFICATE OF6(G Os�]��ryOM WORKERS'
COMPENSATION INBORANCE
fists section need nos W Completed if the permit is for one hundred critics ISIM)
or Ifo.)
1 certify,that in the performance of the work for which this permit is issued.1 shall nue
employ any person in any manner an as in We=subject to the Worlmrs Compensation
Laws of Calirrmis.Dale
Applicant
NOTICE TO APPLICANT:IL after making this CeniOca,of Eaempion,you should
Worm,subject to the Worker's Compensation provisions of 1W Ulaor Cock.you most
.JO forthwith Comply with such provisions or Nis permit shall W dcemW revoked.
'Z,..,'7) CONSTRUCTION LENDING AGENCY
I herb elrrm thn ft.iso construction lendin a a for Je
F— Y e .) Y perruomana of
Cw m7 the work for which this permit u issued(Sue.M.Civ.CJ
D, Q I.endcr'i Name
z Underi Address
U0 I certify that 1 have read this mpliearion and sou that the mauve information is
!L FCorel.l agree to comply with all city and county melina ams and sum laws relating in
O U building construction.and touchy ItuhmM mprucmatives of this city to color upon the
W ahovomumirncd pmKrlyts,com andor ex,cNon purposes.
0, (We)agree m ave,indemnify and keep harmless the City of Cupcnino against
fin liabilities,rydgmenu,cnstsandcapr"—which may in en wayaccrue against WC City
fJz inconsequence of Ne ming of rslermi
" APPLICA ON ST ANO W C P WITH ALL NON-POINT Issued by: Date
SOU G
_t 2 b Re-roofs
gnaturc ofA HA2AR US MATERIALS DISCLOSURE Dan Type of Roof
WWillthcapplicamor tum Wildingoccupatssomormmleheurdousmarerial
az defined by the Cupertino Munid al Cade.Uupmr 9.12.&seed tle Health and Safety -
`dC.SaBon25532(n)+ All roofs shall be inspected prior to any roofing materiadldbeing installed.
Yns u J
Will thea meant or future building oar ant one a If a roof is installed without first obtaining an ins ecngn,I agree to remove
Pr t p quipmcnt or devices which g p f
emit hawardoua air contaminans u fined by the Bay Area Air Quality Management all new materials for inspection. �r5
Count?
❑Yes
[have real the Is anidous ma¢rialssequinmema undcrC ser G95rf&Califor.
riaHealth&Safety Code.Sections 25505.25533 anJ2554.1u and thxtifthe Wilding
does not Currently have a moans that'-i re ility oul'y N.e om ant nr Ns 7
myuimmc0!whit x mprio axnar c mofBa+aM4 ,Signature of Applicant Date
Owner or i .ed agent wt6 All roof coverings to be Class"B"or better