04040034 CITY OF CUPERTINO ' ��r '
BUILDING DIVISION PERMIT i"CONTRAXV XI `^ORMATIOM. "
BUILDING ADDRESS: PERMITNO.
04040034
R'S NAME: PERMIT ISSUE DATE
fI0
' PH NE: SANITARY OL NO.
ARCHITECT/ENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
LICENSED CONTRACTOR'S DECLARATION
i 1 M b55yy''''.form that I ars 1'.. d der provlatona of Chapter 9(commencing Job Description
n< Amsection7 fDivisiun3ofthc BY sand Profcseiuns Codc n ccnm is
in full fo+ o d �j i
6n: Lieeam s m.R REVISION--BEAM
4�pppppp 3. Con lar NO NEW PERMIT ISSUED/ORIG. #03100028
Yq ARC llWuw D� ATI
YY 33 Ia�mywmyplanaahallMuse uNicrtc"Ns CONTRACTOR: TEK CONSTRUCTION
ZLicensed Pnafcssional
OatNEmBUILDER DECLARATION
1 h.. .(firm that 1 1. ,Business
from the Contractor's License Lew for the
C O following mason. armil t 703 construct,
Business and Professions h.m Any city m county
ctum
u�$� which in Issu s permit m construe,alma improve,dcamish Permit u fi repair any amment
F�0 prior that he in Issuance.pualsrsuant
to threse
the
ovisio so thefor sucContractor's
micense Law
statement
FF p (comm limnmdpurction7 th)ofDivions 3arthe ntncmriLimn¢Law(Chapter
Code)
Sq.Ft.Floor Area Valuation
N
(comm acing with Section and the
Wass
for ft al Buseged exemption.
Pmianon.An vi Crile)or
3$
that he"is exempt therefrom and me Msis for me alleged 4xemptlon.Any violation of
Section 7031.5 by any applicants for a permit subjects the applicant In a civil Penalty or APN Number Occupancy Type
not mom dun Ove hundred dollars($500).
❑1,u owner of the property,or my employees with wages or their sole compensation,
will do the work and thesmcturt isnot intended or offered for rule(San.7046.Business 37540030 . 00
and Professions Code:The Conmcmra License Law does nm apply to an owner or Required Inspections
property who builds or improves thesmn,and who does such work himself or through his
aw...plassu,provided that such improvements am nmimanded m offered for sale.If.
however,the building or improvement is to within"rte yearorcompleuon,to owner-
builder will have me human of proving that W did not build or Improve fm purpose of
sale)
0 1,u owner of the property.am exclusively contracting with licensed contractors to s
construct the project(sec.7044,Business sod Probations Code:)Toe Contractor's Li-
ceme hw not apply to an owner of property who Wilds or improves thereon,and
whoco clafor such projects with a contrumr(s)licensed pursuant m the Contractor's
c Law.
am exempt under sec. 0&P C far this moon
erDate
WORKER'S COMPENSATION DECLARATION
1 hereby amen under penally of perjury one of the following declarations:
I
0 I have and will maintain a CeNOwm of Consenita self-inmm far Wmk&sConPcn-
utlon.as provided for by Section 3700 of the Labor Code,for the performance of the
work for which this permit is Issued.
0 1 have and will maintain Worker's Compensation Insurance,as required by Section
37W of the labor Code.for the peformantt of the work for which this permit is Issued.
My Worlm's Compeuation Insurance carrier and Policy number am:
Carrier: Policy No.;
CERTIFICATE OF EXEMMON FROM WORKERS'
COMPENSATION INSURANCE
(Thkscctim,need nm W completed ifthe permlO,for a..hundmddnllau(SIM)
or Russ.)
I certify that in the r1hro enee of the work for which on�p_er]�m�Riptaj' 'ssucd.1psehye[leltnInot
employ any pcssonm ncrsoum Wcomes "" inn
Isw..a(^alilbrnij D�a c t%b�
ppp'1
NOTIC 0 AP W ANT:It.orw making this Certificate of Exemption,you should
but, a subject to the Worker'.Compensation provisions or the uth r Cedc,you must
Z forthwith comply with such provisions or this permit shall W doomed Invoked.
zO CONSTRUCTION LENDING AGENCY
[-a 1 hemhyomrm that there les commotion lendingag.My for the perfmmmce of
[�r7 the work for which this permit is issued(Su.3097,Civ.C.)
aQ Lendcr's Name
2 Lender's Address
U Q 1 certify that I have mad this application and elate that the above Information is
IL F comet.I agree In comply with all city and county ordinances and stoic laws hitting m
V building construction,and hereby euthorim rcprc etives of this city in enter upon me
W above-memioned property for inspection pus s.
0. (Wc)agree m lave,indemnify op hunk the City of Caronino egeinsl
h
usellitlu.juIt menu,tom ander swhich neny way.came against said City
f)7 ipnPPLICgA eofmc u"DS AnNpermILL COMPLY WITH ALL NON-POINT Issued by: Date
�i
So,
ON&
_ Re-roofs
Ir gra fAppl HAZARDOUS MATERIALS DISCLOSURE ate Type of Roof
;9��
antsfumrt building IALSmstemOURIred ber in"Mun" al Codc.Chapter 9.12.and the Health and Safely
Sectio ). All roofs shall be inspected prior to any roofing material being installed.
❑YNuWiII am or furore Wildin cupetr use cyuipment or dcvicu whichIf a roof is installed without first obtaining an inspection,I agree to remove
[mil h®ardotaminants as J by the Ba maAirGaalityManagement all new materials for inspection.
District?
0YeIhavas rostra smquimmcnuundcrChapter6.95ordmCalifor-
niaHcalm ,Smuo 505,25533 and 25534.1 understand that ifthe Wilding
docs not c • ,mal it I¢my rGponslbility m nosily the coutpart of me
require. met priorInissuanceor eem0e a Signature of Applicant Date
Ow oramhoriaadagcm Dam All roof coverings to be Class"Bra or better