03100028 77777
CITY OF CUPEWTIN0
BuaomcDlvlsloN PERMITeONT1TC?�2INI�OIZYYIATTd1 .
BUILDING ADDRESS: PERMIT NO.03100028 310002.8
qTRNT-)TJAT TN
OWNER'S NAME: PERMIT ISSUE DATE
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SANITARY NO. 2 CONTROL NO. -
ARCH1TECEENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
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i
00 LICENSED CONTRACTOR'S DECLARATION �t p
£ eta with I hereby arum
that 1.m licensedorder provision:of chapter v(commencing Job Descrip To
Section 9111)0)or Division 3 of the Business and Professions Code,end my license is
0.
in full fomeantl effect. ADD 596 SQ. FT. a/
to
n_ License Class Lie.N - UN q
❑ Dam Contractor 6
I understand my pl ns hal M u ed as Ferulic rA cords 2007
tS.U,
Licensed Profevioml
g OWNER-BUI LDER DECLARATION -
<S 1 hereby affirm that 1 oto exempt from the Contractors License Law far the
p 0 following mason.(Section 7031.5,Business and Prefeesium Code:Any city or county
<m which requires a p.it m construct,site,improve,demolish,or repair any slrumure
prions its issuance,also requires the applicant for such permit to file a signed statement
< that he is licensed pursuant to the provisions of the Contmcmri License law(Ch.ptor9 Sq.Ft. Floor Area VaIUBIloO
tstp (commencing with Section 7")of Division 3 of the B usincss and Professions Code)or
3 Nal he is exempt therefrom and the basis for the alleged exemption.Any violation of
Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of 3•AMl348ter00 Occupancy Type
nm more Nan fat,hundred della.(SSW).
❑1,as owner of the property,or my employees with wages IS their .In nmpenm0nn,
will do the work and rte structure is not intended or offered for sale(Sec.]094,Business
and Professlom Code:The Contractors License Law does not apply to.n owner of Required Inspections
propeny who builds orimpeaves themon,and who doessuch work himself or through his
own employees,provided that such improvements are not intended oroftered formic.IL
however,We building or improvement is sold within one year ofcompleuon,the owner- -
builder will have the burden of proving that he did not build or impmw for purpose of -
s;1eJ.
1,as owner of Ne property,am exclusively contracting win licensed contractors to
constrict the project(Sec.7044.Business and Professions Code:)The Contmctorh Li.
cense Law does not apply to an owner of property who builds or improves themon,and
who contracts for such projects with a commercials)licensed pursuant In the,Contractors
License Law.
I ton exempt under Sec. B St�P�C for this resson -
wNe,U 7tii / Dam
RKER'S COMPENSATION DECLARATION ( _
(hereby affirm under penalty of perjury one of the owing declantiens:
I have and will maintain a Certificate of Consent to self-insure for WorkersCompton-
sation,as provided for by Section 37M of the labor Code,for the performance of the ,
work for which this permit is issued.
❑1 have and will maintain Workers Compensation Insurance,m required by Section
3700of I.Labor Code,for On perfmpa mof the work for which this permit is issued.
My Workers Cnmpens ium Insurance artier and Policy number am:
Carrier: Policy Na,:
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(This section need not he completed i(the permit Is foronchundmd dollars(210)
in,less)
1 ccnify that in the performance of the work for which this permit is issued.I shall not
employ any person in any manner an as in become subject to the Workers'Compensation -
Laws of California.Deve
Applicant
NOTICE TO APPLICANT:IL after making this Cenificam of Exemption,you should
become subject to the Worker's Compcuation previsions of he Labor Code.you must
Oforthwith comply with such provisions or this permit shall be deemed revoked.
Z rCONSTRUCTION LENDING AGENCY
I hereby affirm that there is a construction lending agency for the Performance of -
Y, r7 the work for which this permit is issued(Sec.3097,Civ.C.)
YQ Lender's Name
�.z Lender's Address -
J Q I ccnify that 1 have read this application and sure tht Ne above information is
y H correct.I agree to comply with all city ad county ordinances and alms laws relating to
�U building construction.end hereby mthnrim repmsentativcs of do.city to cnlerupna the
(T•j .have-mentioned property for inspection purposes.
(We)tog.1.save,indemnify and keep harmless the City of Cupertino against
r h
liabilities,judgments.casts end expenses which may in any way accrue against mid City �•5
JZ in consequence of the granting of this permit.
^' APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT Issued by: Date
SOURCE REGULAT 5. s
H Re-roofs
� gactor
naturcef App •HAZARDOUS MATERIALS DISCLOSURE Type of Roof
Will We applicant or future building occupant atom or handle ha�ous material
u defined by the Cupeninn Municipal Code,Chapter 9.12.and he Health and Safely
CoJc,Section 25532(a)? e All roofs shall be inspected prior to any roofing material being installed.
❑Ye
Will the applicant or metre building Occupant use equipment or devices which If a roof is installed without first obtaining an inspection,I agree to remove
Kit heaallous air contaminants as defined by he Bay Area Air Quality Management all new materials for inspection.
District?
0 y XNo
I have mad the hamolous materials mquiremcats under Chapter 6.95 of the Califor-
nia HcolN a Safny Code,Sections 25505,25533 nd 25534.1 unde..d that i(Ne building
does not currently how a mnmt not it is my responsibility to nobly the acupnt of the
mquimmcnts whish mum be tont prionafuuncc of a Ccrdficam of Oecupncy' Signature of Applicant Date
bsuu N ) r 0�3
Owner W I ,.xd agent Dare r All roof coverings to be Class"B" or better