05080070CITY OF CUPERTINO
'OItM�.I'IUh(
BUILDING DIVISION PERMIT
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QI2, TN
4.
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BUILDING ADDRESS:
COBE CONSTRUCTION
PERMIT NO() 5080070
OWNER'S NAME:
PERMIT LSSUH DA7E
E:
SANITARY NO. CONTROL NO.
(408)371-3400
ARCHITECf/ENGINEER:
BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
0 0 0
LICENSED CONTRACTOR'S DECLARATION
Job Description
1 hereby that 1 am limned under provision of Chapter 9 (commencing
p
with Section 0) of I,
Division 3 o the Business and Profession Code, and my license is
Nrmlmroas «.
and
TI-- INTER. WALLS /T -BAR /CEILING &
Lkenso Clew Lk.g
Dam contractor
BATHROOM/MECH./ELECT./TITLE 24
ARCHITECT'S DECLARATION
I undcnund my plans shall be used as public records
TEMP PERMIT #05080223 (EXPIRES 09/23/05)
Licencd Professional
OWNER- BUILDER DECLARATION
I herchy affirm that I am nampt from the Contractors License law for the
fallowing morn. (Section 70313, Baines; and Profession Code: Any city an county
which acquires a Tamar, to consumer, alter. harrow. demolish. or repair my structure
prior an its issuance, also inquires rue applicant for such permit to file a signed stsement
that he is licensed pursuant to the provision of the Contractor's license Law (Chapter 9
Sq. Ft. Floor Area
Valuation
(commencing with Section 70DD) of Division 3 of the Business and Professions Code) or
1 6110
But he is exempt the efrom and the buts far the alleged exemption. My Holadon of
y`
APN Number
Occupancy T7 p e
Secdw 7031.5 by any applicant for a permit sabjecu she applicant m a civil penalty of
not mom than five hundred dalhrs(S500).
❑ 1, u owner o(the property, m my wplaym wish Wa{ea as Heir sole eompenution,
RegUlr I
wiBdo Nework and rue swcmrt a not intended arafferW for We (Sec. ]014, B W rcu
and Professions Code: The Contractors License Law don tot apply to in owner or
s eectiossn 1(71
property who Wlldswimpow themoat and who does suchworkhimselforthrough his
ly I ��
own employees, Provided that such Improvements are Out intended warranted for We. if.
t� -71.�
however, the building or improwmmt is sold within arc year of mmpledem. the aWmry
IHl
Wilder will have the burden of proving Wr he did nor Wild or improve for purpose of
"It.).
st l
S
I. u owner of the property. me exclusively contracting with licensed mnm ern to
OCT Loosl
C t
eruct rue project (See 7044. Business and Professions Code:) The Contractors U.
tense law does not apply to an owner or property who builds or improve.; Neon, and.
y**t� s
(pp
WIm for each proje ts wiNamnuacto(s)Iiansed PuDwacamme COn,ne_ wrs
Tttj f
cmnua
Law.
jl
BUILD
Dram nSe ,Bg:PCfortiiam
Owner
WORKERS COMPENSATION DECLARATION
I hereby affirm under penalty of perjury me or the following declaration:
�Nw
and will maintain a Cenifncate ofConcm to self -inure for Workers Compcn.
: Bon. as provided fer by section 3700 of me labor Code, fn the performance of the
work for which this Permit is issued.
❑ I haw and will maintain Workers Compensation Insurance, as required by Section
3700 of the labor Code, for rue performauce of rue wort for which NU permit is issue
'
My Workers Compensation buunnce curia and Policy number art:
Carver. Policy No.:
CERTIFICATE OF EKEMFnON FROM WORKERS
COMPENSATION INSURANCE
(Thus cNm aced wt be completed Ifthe permit is for one hundred dollar (SIM)
or IuaJ
1 cenify that in the perfarmauce of the worst For which this Permit is imed, I shall not
employ any person in any man sr utob one abject tote w0flecrecompensadan
Laws of Caliroania. Dau it
Applicant ben &1I l 11t
Isd
NOTICE TO APPLICANT: If, aft making this Cemnnesto of Exemption, you should
became subject to rue Woneces Compensation provisions of rue labor Code, you mum
forthwith comply with such provisions or this Pewit Mall be deened raveled.
CONSTRUCTION LENDING AGENCY
1 bemby Mr. via ft. ... onstructnn lending agency for Ne perfowanm of
the work for which this permit u iauW (Sec. 309], Civ. C.)
Leaders Name
'
Landers Adders
1 ceNfy that 1 haw mead this application and sum that the chow information B
WMMI agree to comply with all city and county oNlnances and scale laws relating to
building construction, and hereby authorise representatives, of this city to enter upon the
above - mentioned property for inspection purposes.
(We) agree to taw, indemnify and keep harmless the City of Cupertino against
liabilities, judgments, casts and expenses which may In any my acco against and City
in consequence of the granting of this permit.
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON -POINT
! G
Issued by: Date G-
SOURCE,PCJ1ULIjT10NS.
Re -roofs
Type of Roof
Signature f on
ApplicanUCtractor Dam
HAZARDOUS MATERIALS DISCLOSURE
Will de applicant or future building occupant nom orhaudle haumdous mammal
as de0ond by the Cupertino Municipal Cade. Chapter 9.13, and the Health and Safety
Code. Section 3ssu(a)7
All roofs shall be inspected to any roofing material being installed.
❑ Yes Al
0
prior
/ `
If a roof is installed without first obtaining an inspection, I agree to remove
or future building occupant ere m devices which
Will the all
II hnartlnua tit conuminanu a dcRdcd by dm Bay Arm Air QuWty Mongemcm
cmut m Ail Quality
all new materials for inspection.
stricl7
❑Yea (Q�u
I hewacW the Marl mamriaumquimmenuunder Chapw,6.95afthe Califoo-
nix Heal" Safety Coda. Sections 75505.35533 and 35534.1 underhand thaifthe building
'
Jan wt currently haw a meant. that it is my responsibility m notify rue eccrpanl of rue
myuinmenu which must he mm prionaiuuan ar. Ccrtilicam of urany.
Signature of Applicant Date
QgON 1G q /�1 uLk A
All roof coverings to be Class "B" or better'
_�L
Owner
m authorized agent Dom
a