04080158 CITY OF CUPERTINO ✓€ � `��" `
BUILDING DIVISION .. PERT ACQNTRn! - R� OA ar.UY T ON . . -
BuaDINGADDRESS: APPLIED CONSTRUCTION TECH PERMIT'904080158
100 N STP.TT,TMr PT)
OWNER'S NAME: PERMIT ISSI EDATE
ASSEMBLY O -ogo .04
E:
SANITARYNO. CONTROL NO.
(408) 252-9990
ARCNI'IF.CT/ENGINEER:
BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
0
septi LICENSED CONTRACTOR'S DECLARATION JobDescri do
1 hereby affirm met 1 am licensed ands,provisions of Chapter 9(commencing - PNNALED
?mawith Sectim,700 s)of Division 3 ofmc Business and Pmfemn nn Code,and my license is
y in full Tose andeffect TI--ROOF STRUCT. REINFORC.
c�z Datenm Cl"r Contractor ✓ ,I
ARCHfiECTS DECLARATION N1ffrs7
v OI 2004
�i 1 undersand my plans shall he used as Public retards
BUILDING
3u. Licensed Professional
50 OWNER-BUILDER DECLARATION
0 f I hereby.(firm that 1 1 exempt from me Connector's License Law for the
Oo which requires
permit
a'HDIS.B"lase and Professionss. le:Any city nrmua,
$lei which rsquirns•permit m mnanei.alter.improve,demnl W.or repair any nmaum A A 9 "
t„iy priarmits i"uance.als�requites the applicant for such permitm fileaeigaJ sutemeni
< thathcisliamedpursuaammeprovisionsofdueConnamr'sLicenseLaw(Chmtcr9 Sq. Ft. Floor Area Va nation
at (commencing with Section 7M)of Division 3 critic Business and Professions Code)or.
that he Is exempt therefrom and the b"k for me alleged exemption.Any violation of
Section 7031.5 by My applicant for a permh subjects me applicant to a civil penally of 3 2e5IlN1fb*e10 0 Occupancy Type
on,mom then five hundred dollars(SSW). .
0 L"ownm drove property,army employees with wages"theastAccompen"don,
will de me.&.and a mocone isnotiatmd muffered fmadc(Sm.7044,Business Required Inspections
and Professions Cade:The Connector's License Law does not apply m e an owner of q P
property who bu ll ds err improves theson,end wha does ouch work himself or though his
awn employes,provided that such improvements art not intended aro@red for ask,IL
however,the building or improvement is sold within one year of completion,see owmr-
builder win have dte Wades of proving that he did not build or Improv for purpose of -
"le.).
0 1,as owner of Use property am exclusively contracting with licensed contactors to
consumer the project(Sec.7014,Business and Professions Code)The Conuactar's Li-
cenm Law docs not apply to an owner of property who Wilds or improv thereon,and
who contracts for such projecla with a coarecmr(a)licensed puramm,in Ibo Contractors
License Law.
0 tun exempt under See ,B&PC for this rt"on
Owner Data
WORKER'S COMPENSATION DECLARATION
I hereby affirm under penalty of pejo,,oro of the following decluadons:
1 have and will rummuin a CeniRnm acmiscut to ael6lnsus fa Workers Compcn.
"tion,as provided fa by Sation 3709 of the Ube,Code.for see pcarmanmro of sed
work for which this permit is issued.
0 I have and will maintain Wakeri Compensation Insurance,"required by Section
3700of the LsborCodl for the,perfarmana of the work for which this permit is issued.
My Worker,Compensation lmunnce carrier and Policy number Me
X Carrier: Policy No.: _
CERTIFICATE OF EKEMPTON FROM WORKERS'
COMPENSATION INSURANCE
(rhh section reed mat W completed if tie permit is our onshundrW dollant(SI W)
or less.)
1 certify that in the performance of the work for which this Permit is banned.I shall not
employ any Perron in any manner an a to became subject o the Warkma Compenuumn
Laws of California.Data
Applicant
NOTICE TO APPLICANT.If.after making this Certificate of Exemption,you should
become Subject he me Worker's CamPewdon previsions of the IaWr Cade,you most
�O forthwith comply with such Provisions or this permitsmmv
hall W accused nkcd.
y14 CONSTRUCTION LENDING AGENCY
H I hereby affirm mnmem is construction lending agency for me performance of
C'
the walk for which this permit is issued(Sec.3097.Civ.C.)
QLenders Name
= z Landers Add.
U Q I cenify that I have read this applicaion and sate than the above inform W un is
If.F•' correct 1 agree to comply wit all city and county ordinances and sea laws slating to
DUbuilding construction.and hereby euthoriec repremmaJves of this city to enter upon me
N W shove-memiuned property for inspection purposes.
M. (We)agree to"w,indemnify and kap harmless the City of Cupertino against
Ilabilid",judgments,coats and"pemms which may in any way stems agaiml said City
U Z, in consequence of the gaming of this Permit.
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT Issued by:3 Date
SOURCE REGULATIONS.
Re-roofs
Signature ol'Applicand/Cmarrachur
HAZARDOUS
Date
n Q
HAZARDOUS MATERIALS DISCLOSURE Type of Roof ®
Will the ems to fuuni Wilding occupant r9.1 a handle hasNouad
Stesi
"defined Usa e Cupertino Municipal Coca.Chapter 9.12.and the Helm andd Safety
cCode. a
0yb,2ss3zler All roofs shall be inspected nor to an roofing material beim installed.
❑Yds ON. P prior Y g $
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
mit h.kerdoos air manaminanu as de0ned by the Bay Area Air Quality Management all new materials for inspection.
District?
❑Yes ON.
[have mad see h"ardam materials mquimmcnu under Chapmr6.95of thc Califor-
nie)kala&Sdmy Code,Sectiam255O5.25533and25534.1 undersundukifue Wilding
does not uncntly how a tenant.that Is is my ssyonsibility,in notify Use occupant or the Jntin
requirements which must W met prior a issuance of a Comficaa of Occupancy. Signature of Applicant Date M
Owner err duthmixod agenl Date All roof coverings to be Class "B"or better