04120052CITY OF CUPERTINO ..
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BUILDING DIVISION PE RT
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BUILDING ADDRESS:
W A CRAIG INC '
PERMIT
O O S2
EWS NAME:
PERMIT ISSUE DATE
ONE:
SANITARY C OL NO. -
ARCH171=1E4GINII
BUILDING PERMIT INFO
.
BLDG 'ELECT PLUMB MECH
LICENSED CONTRACTOR'S DECLARATION
Job Description
1 affirm L am under of Chip¢& 9 (mmmcnw
d Pmfcu is
alfa Satisbwd.)WDiviuon]of the Buuncu and Profculone Code,and myliconmu
ion 7 ivis f ft R
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mmnitadamaerrmL,
puce Lk.g
TI--OZONE. INJECTION @' 76:GAS STATION -• _.-..... .
Dam - COn
Dam
DECLARATION
-
I undenund my prism shall be rued u pruhlm records
all be used inpublic
Liccnand Pofeuinal
• OWNER-BUILDER DECLARATION
'
I hereby arnre that I am exempt from the Conueaars Ucemse Law for LIR
following mason. (section 7031.5, Business and Pmfeenions Code: Any city or county
which requires a permit in construct. user, improve, demolW, or mpur any maxum
n n
prior in Its Issuance. also requires the applicant for such permit m Me a signed mmmem
that M u licensed purmmt m the provisions of inn contractor. Umme Law (Chapter 9
(commencing with Sudan 7000) of Division 3 of the Businenand Profwion&Code)or
- Sq. FI. Floor Area !f \ ` ff+7 Valu tart
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that he is exempt therefrom and the Was far the illegal exemption. My viaWlon of
3 7OHNIMIlICIO O Occupancy Type -- — --- -'
Section, 7031.5 by any applicant far a permit subjects the applicant to a civil penalty of
nor mom than live buMmA dollen (5500).
❑ I.uowneroftha popertY.armyeatployaa with"Sam thassabscompenallon,.7On.-
r <''d _
r/(� Required Inspections ., . _ .
will dothe work. and theewctmk arm Intended or oRernd for dn(Sm. 7066, Bahamas
and Profession, Code: The Conuamob Liam law does not apply to an owner of
daamchw khi vforW ughhb
,. )I
(V�-( ,! 11own
pmNnywhabulldsarlmpoveatlmrmn,aMwl
employees, provided than such improvements are not(nmMed arolfened for We. If.
homever, Ne building or improvement is mid within arc year completion. the owner
builder MB have the Widen of proving But M did not build or Improve for purpose of-
ulad. _
tm1. u cancer of tion property am exclusively conusoMg with licensed conaaenon to
unmet the project (Sec. 7064. Business and Profnu les Code:) TW Contractor!, U-
anon law it. not apply In m owner of property who builds or impoves thereon, and,
•- - - _ � _ _ _
who eontrama for such projects with a mnuactaKU licensed personnel write Conaclora
License law.
❑ 17 Lunda son,
nos for this
h�
{Dai' C'od C
W K OMPPNSATION DEC N"
1 hereby affirm under pemllY of pe7ury oneof the allowing declarmhumv.
..
if-is far WorkceiCorepen•
I him and will maintain a Certificate of Consent ocomu
union, u provided fa by Section 3100 of the Later Code, for the performance of the
wok fm which this permit is Issued, - - - -
I have and will maintain Workefa Compensation Insurance, as required by Section
. .
3700 of the labor Code. for inn prXormanaof the wok forwhich this permit is laved.-
My Workers Compensation Insurance surce carrier and Policy number are:
Carrier Policy No.:
_
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(Thlsmetion omit not W completed if tiR permit is foronehundrnddo0an (6100)
m less.)
I acidly that in the performance of tice work for which Wspermit U issued. I shut net
employ any parent in my mannerse u at became abject inthe Workers Comperiadan
Laws of California. Dam
_
Applicant
NOTICE TO APPLICANT: It, after making this Cmuncale of Exemption. you should
become subjm in the Workers Compensation provisions of the Labor Code, you most
forthwith comply with such provisions or this permit h.11 be deemed remkcd.
CONSTRUCTION LENDING AGENCY
'
1 hereby affirm that dem is a cnmvuNa lending agency for din Performance of
the mums fur which this permit is issued (Sec 3097, Civ. C.)
Lenders me Na
Landers Name
I certify that I ban road this application and suis thin thea mom InrormNon is
cone. I qac in comply with dl city and county oNinances and sum laws relating u
building comwetion, and hereby maintain: repremnutims of this city in enter upon the
above-nueni00ed property for ImpcmlOn PmP ma
(We) agree to save, indemnify and keep harmleas the City of Cupertino against
liabilidra, judgments, case and expenses which may in my way wove against suit City
in consequence of tie Starting of this permit
APPLICANT UNDERSTANDS AND WILL COMPLY WITH.ALL NON-POINT
Issued by: Date I
SO REGULATIONS.
)UZAE2
Re-roofs
.lure of AppHcanV antractor
HAZARDOUS MATERIALS DISCLOSURE
Type of Roof
Will tic applicant or future building occupant nom orhendic bauAau maeriu
as deMcd by tie Cupertino Municipal Code. Chapter 9.13, and the Hcdth and Safety
Section 25532(.)7
`¢Na
All roofs shall be inspected prior to any roofing material being installed.Oyer
If a roof is,installed without first obtaining an inspection, I agree to remove
Will the applicant or future building =open, use equipment or devices which
soh heard.. air mnuminanu in defined by the Bay Area Air Quality Management
all new materials for inspection.
District?
❑Yes �No
I have mad the huaNnusmaerialsrcquimmeriu underChxp tr 6.95of tic Califon
nu HUI"SamlYCodc. SectiaresIM5,25533 md25S34. l understand this fine building
does not correctly hove a Rant, that It u my responsibility b nodfy the occupant of ftaqui
uwhim manic met 'ren ismame of a ccmficsm of acupancy.
Signature Of Applicant Date
!cH girl Iz
All roof coverings to be Class "B" or better
Owner ormthori ed agent Dam