04070007rY OF CUPEKI INV
BUILDING DIVISION PERMIT
ARCHITECT/ENGINEER:
I hereby affirm that I am licensed under provisions of Chapter 9 (commencing
with Soclion 701Mp ol'Division 3 of fee Businesaand Posessimes Code, and my license is
in full force end effecl.
License Class Lic. N
Date Contractor
ARCHITECrS DECLARATION
1 understand my plans shall W used as public records
OWNER -BUILDER DECLARATION
1 hcr,hy Mo. 'list I em cacmpt from fee Canumnsr'a Licenm Lew I'ur the
following mason. (Section 7031.5. Business and Professions Code: Any city or county
which requires a Permit to construct, also. improve, demolish, or repair any structure
,binto its issuance. also mqe uirthe applicant for such permute file a signed smm
teent
that he is licensed pursuant se the previsions of the Contmmus License Law (Chapter9
(commencing wife Section 7000) of Division 3 of the Business and PrafessionsCmle) or
Nat he um
ampt themlrom and Ne basis for the alleged ummpdon. Any violation of
Section 7031.5 by any applicant for a permit subjects the applicant m g civil penalty of
net more thirst Ove hundred dollars ($500).
❑ I, a owner of the property, or my employees with wages Out their sole compensation,
will do the work and the someone is not intended or offered fonale (Sec. 70,14, Business
and Professions Cod. The Co men r't Lie.re Law docs not apply in an owner of
property who Wildsor improves themon, and who doessuch work himeelfor through his
own employees, provided tha'such improvements are not intended oreffemd forage. If.
however, the building or improvement Is sold within one year of completion, the owner.
builder will ham the burden of proving that he did not build or improve for purpose of
sale.).
Ibi 1. as ..or of the property, am exclusively contracting with licensed convectors to
{jnslmet the project (Sec. 7044, Business and Professions Cade:) The Contractors Li.
cense Law docs not apply to an owner of property who Wilda or improwt thereon, and
who contracts for such pmjec%wife a commensals) licensed pursuant to the Committees
License Law.
❑tem axe pt under gee. r,BkPC(or dela mason
Owtf� Date �/
WORKER'S COMPENSATION DATION
1 hereby Orion under penalty of pe jury one of the fallowing darli ntlons:
haveendwilln man a CcmBcate of Consent to sel6inuum for Worker's Compen.
1dun. as provided for by Section 3700 of the Labor Code, for fee performmes of the
work for which this permit is issued.
❑ 1 have and will maintain Worker's Compensation Insurance, M required by Section
37W cribs Labor Code, for the performance of the work forwhich this permit is issued.
My Workers Compensation Insumnm carrier and Policy number am:
Cartier: Polk" No.:
COMPENSATION INSURANCE
(Otis section need notbecomplemd if the permit Is forms, hundred dollars (1100)
or cam.)
I certify that in the performance of the work for which this permit Is issued, I shall not
employ any person in any manneres as to become subject to the WorkersCompensation
Laws of California. Date
Applicant
NOTICE TO APPLICANT: If, arm, making this Cmificate of Excmplion. you should
become subject to the Worker's Compensation previsions of the Labor Code, you must
forthwith comply with such provisions or this Permit shall W dccmcd revelmd.
CONSTRUCTION LENDING AGENCY
1 hereby affirm that there is a construction lending agency for be performance ser
the wurk for which this permit is issued (Sec. 3097, Civ. C.)
lender's Name
Lender's Address
1 certify that I have mad this application and sale deal the above inforemun is
correct. I agree to comply with all city and county odium a s and state laws printing to
building construction, and hereby authe es mpre maivus of this city to enter upon the
ahovc-mentioned property (or impection purposes
(We) agree to rave, indemnify and keep harmless the City of Cupertino against
liabilities, judgments, costs and expenses which may in my way acme against said City
in consequenco of the granting of Ibis permit.
DS AND WILL COMPLY WITHAof 0/12 -POI*
SOUR REGgLATtONs
Sigmas. o(AppiicmvCentraeor Data
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future building occulum atore or handle hormones material
as dented by fee Cupertino Municipal Code. Chapter 9.11, and the Hcalth and Safety
Code, Section 25532(a)?
I[-]Ycs 1Q No
Will the applicant or future building occupant use equipment or devices which
i' bumptious air contaminants as defined by the Bay Area Air Quality Management
slricl? ���/11
❑Yes D1No
I have maad the hsrmsess v`smaterials requirements under Chapter 6.95 of the Califor.
nia Health & Safety Cade, Sections 75505,25533 and 25534.1 understand that i(the Wilding
dors not mormly how a Imam that it is my responsibility to notify Use meopmt of me
rsnuedhcnts which must be mel prior to issuance of a Cereficau, of Occupancy. a
PERMIT NO04070007 40,7000,7
PERMIT ISEUHDATB
n-7 /nT /onna
SANITARY N0. CONTROL
BUILDING PERMIT INFO
Job Description
BATHRM REMORN IEDOM)
SEP F3 2004
Required Inspections
Issued by:
Re -roofs
Type of Roof
li
All roofs shall be inspected prior to any roofing material being installed.
If a roof is installed without first obtaining an inspection, I agree to remc
all new materials for inspection.
Signature of Applicant Date
All roof coverings to be Class "B" or better