05040079CITY OF CUPERTINO
ISue-• x '-'rc s'
MA `I4 1
BUILDING DIVISION PERMIT
YGONTRACTUR TNFU�.
*,� ra.:r y`.X. .�,F 'a, rAe: r.G•*.?in ,.mr .2,701.:.
BUILDING ADDRESS:
PERMIT N00 5040079
ER'S NAME:
PERMIT ISSUE DATE
SCOTTRADE
NE:
SANITARY NO. CONTROL NO.
ARCHITECTIENGINEER:
BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
0 0
LICENSED CONTRACTOR'S DECLARATION
Job Description
1 Wreby affirm Nat 1 am Iunder provision of Chapter 9 (commencing
_
with Section ]110)of DNalon 3 of ft Baalau and ProfessionsCade. and my Ilcene u
th full force and eEen. Z
TI--NON-STRUCTU. INTER. TI &
kenm Clan Lk.♦
L".1.0
Dam Cummcuw
LITING/DEMISING WALLS
ARCHITECTS DECLA Io
I undersand my plain eha111e uea sa public recmds
CONTRACTOR: JDT INC (RECEIPT. #01000012041)
fcainre
LinacPml
OWNER-BUILDER DECLARATION
I Wreso .(sero that 1 License Law forthe
utmpa from the CaroanCod
Audi Cate: My city county
1. :
meson. (Schon ]831.3, Business; and
which
re re eor alms improve, ri a
which improve. m mauls any anucum
•.
alpermit
h Permit
Primmitsiensedpalant W the IW ,pions of forthe Co permitmfile masigned atakment
its Wu s an
thmWle licensed pursuant 700the of the Comsiness LIeenSeLaw (Chapter 9
Sq. Ft. Floor Area 9 Valuation
(commencing 70thweefrSection of Diatom
Division r the ns of
and Prefsisdon.
`005 18000
assu
that W ts exempt IWrefrom W the pests for the al1egW urmpaon. MY violetitn m
rn and the the alleged my violad n
rl
tion 7Nin fes 6 napp applicantA Permit ab,ene the apple L m a mvd penalty of
f
APN Number Occupancy Type
nodi($51)(3).
❑ 1, as Owner of the Property, or my employes with wgu u their sore compensation,
wllldntbowork.andthe aounumisnotinten&dorortemdrw Me(S=.70".Busimas
-
Required Ins
and Fred ..I m Cade: The Coruscate. Lie•.. Law dao not apply 70 an owner of
eas
q p cu
propany who listener Improve, tee mon, ad who dou.uch work himself or through ho
'
awn employees, provided thatauch improvements sae not Intended ma@ren for sale. If,
however, the building or Improvement I. aid within mm year of completion. the owner.
builder ME have its burden of proving that he did not Wild or Improve for purpose of
ale.).
❑ 1, as owner of the property, am aaelu,ively contracting with licensed contractors to
contract the prokm (Sec. 706, Business and Protonium CodeO TLe Conuwtoes U.
come Law data not apply to in owner of property who Wild, or Impmm theater, and
who contracts for arch projects with. eormactor(s) licensed pur.ant to the Coruscate,
Lice. Law.
,BkPCforthismsaun
u DamWORKERS
ilamaempturderSec
COMPENSATION DECLARATION
I Wreby allom under penalty of perjury ism of hie following declaration.:
1haw and will maimam a Certincmmof Consent to elf-In.um for WorkcM1 Compen.
on, u Provided for by Section 3700 of the Labor Code. fm the performance of the
wart for which Ni, permit is issued.
❑ I have and will maintain Worker'. Compensation Invasion, u required by Section
3700 of the Labor Code, for the performance of Use work for which this pe rreft it leuea.
My Werke aCmmpen�atian ln�wnnm /caller and Policy number em:
Grier. ?k_f7 TV u a,3 Poncy No.: J 7 69D$
CERTIFICATE OF EXEMP 1ON FROM WORKERS
COMPENSATION INSURANCE
(This Section wed notes mattletui If1W permit Is forone hundred dollars (SIM)
or late)
I miry, that in the pufmmace of the work for which this permit is voted. I shall not
employ any person in say manmrso as to become subject to the Workms Compensation
Laws of California. Dam
Applicant
NOTICE TO APPLICANT: IL after making this Cenifluk of Exemption, you Should
become Subject to thc Workers Compensation provision, of the Labor Code, you muco
forthwith comply with Such provisions or this Permit hall W dnmcd smoked.
CONSTRUCTION LENDING AGENCY
1 hereby arm that sem ts a contraction lending agency for the performance of
the work for which this permit is issued (Sec. 3097. Civ. Q
Lendcea Name
Land,ev Address
1 ca ily Nat I have mad this application and sum that the above information i.
urett I agree in comply with all city and county ordineocv and ,u a law mining to
Wilding construction, and hereby authtrim epral nmiM of this city to enter upon the
a arm -mentioned properly for impecuan purposes.
(We) agree to save, indemnify and keep harmless the City of Cupertino against
findlida,judgmenu.ca.ts and expenses which may In any way &=me against Said City
in coneguenn of the imarfng of this permit.
APPLICANT UNDERSTANDS A)ID WILL COMPLY WITH ALL NO -P01
Issued by: Date
SOURCE ULATION .
Re -roofs
Type of Roof
1 chi a
Signaru of ApplianUCanowtor ate
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future Wilding occupant atae or handle hazardous material
as dc8ned by the Cupertino Municipal Code, Chapter 9.12. and the Health and Safety
t. SectiCY:O 25532(a)T a
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 remove
Will the applicant at future building «eap.nt am equipment m sae lee, wraith
mit haardous air contaminants a unlined by the Bay Area Air Quality Management
all new materials for inspection.
District .f
❑Yet '171}9.
I have mad the huardaus materials requirements under Chapter 6.95 of the Califor.
ria Health k Safety Code, S.d. 3113,33533 and 25534.1 unacrsund that If the Wilding
dao ma nay have a knam t It o my responsibility b notrl'y me onupmt of the
rryuirt mm khmml meniamarmeor.cmdrmamace
Signature of Applicant Date
All roof coverings to be Class "B" or better
Owncior e
aulfdifycilagent tam