04090025CITY OF CUPERTINOtes.,a?sR3sLr
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BUILDING DIVISION' PERMIT
(-ON IUC�TO INFORMATION
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BUILDINGADDRFSS:
PACIFIC GENERAL CONSTRUCTI
RRMITND.04090025
OWNER'S NAME:
PERRMITISSUEDATE
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SANITARY 0 OL NO.
ARCHITEC (ENGINEER:
BUILDING PERMIT INFO
BLDGELECT PLUMB MECH
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LICENSED CONTRACTOR'S DECLARATION
Job Description
oP
I hocby affirm Nat I am lim=d uM r pmvuioa of Cl Pwr 9 (mmmencing
with Smtibn 7Ulp) of Division Sof mm Business and Pro(es.oua Code, and my license is
In fdlmmaareae`
Licence Classs Lic.M
License
REVISION -SITE PLAN/PLUMBING
ORIG PERMIT 403100011
Contractor
ARCHITECTS DECLARATION
I understand my plans ahol Is, =4 as public mcnMs
NO NEW PERMIT ISSUED
I-smor lProfessional
OWNER -BUILDER DECLARATION
I hereby affirm that I am exempt from the Convector's License Law for the
following mason. (Sadun 7031.5, Business and ProfeaVom Code: Any city or county
which requires a Permit to eon co ct, armr. improve, demolish, or repair any structure
prior to its issuance. also mimeo tW applicant for such Permit to file a signed statement
Ft. Floor Area
Valuation
that W is licensed pursuant to the provisions of the Conoutor5 License Law (Chapter9
Sq.
wommcneing with Section 7[M) of Division 3 of the Business and Prolamines Code) or
Out he is exempt therefrom and Ne barb for the alleged exemption. Any violation of
APN Number
Occas ane e
y T
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Section 7031.5 by say applicant for a permll abjeets the appnesm to a civil ' Knotty of
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not mom roan five hundred Motion (5500).
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L as owner of tie property. or my employ= with wages as their able compennadon,
3 6 9 0 6 0 0 90 0 Required Inspections
will do the work and the somehow is at intended or offered (orale (See. 7044, Business
and Profession, Code: The Contactors License Law d= not Apply to an owner of
property who builds or improves thereon. and who d=such work himself or through his
own employ=, provided that such improvements are not intanded oro@red forsain. If.
however, Ne Wilding or improvement is sold within oto year.f.moplAtion. Ne owner-
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hoilder win hors the hard. of proving Nat W did not Wild or Improve for purpose of
ata.).
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1, a owner of the property, confessions with licensed eonaaemn
aness
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and Code:) The Contractor's U.
7044, Business and Profao
c son the noct , B
rose Laved es not apply ofpropeny who Wi n
plytoaoith ambo dotheseogad,
who convects forsuch projeN with a contractors) licensed pursuant to to Convanah
orsuch a sedpurr
L ease Law.
❑lam eaemply der Sm. ,B&PC for thisreasen
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�r/IZcc_ Data
WORKERS COMPENSATION DECLA
1 hereby edition under penalty of perjury one of the following declaration:
hese and will maintain a CeNnare of Consent to self -insure for Wbrkerb Compen.
ash.". As provided for by Section 5700 of the Latter Cade, fm the performance of the
work for which this permit is issued.
❑ 1 have and will maintain Worker's Compensation Insurance, a required by Section
3700 of Ne Labor Code, for me performance of the work for which this permit is issued.
My Warker's Compensation Insurance ander and Policy number art:
Cartier: Polley No.:
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(Thu semen need not W completed Ifthe Permit Isforoac hundred dollars (5100)
A, las)
1 cosily Nat in to Performance of due work for which this permit is issued. l shall not
employ any person many manner an As m become subject to the Workerfi Compensation
Laws of California. Doe
Applicant
NOTICE TO APPLICANT If. after making this Cenifieaw of Exemption, you should
became subject to the Worker's Compensation provisions of tW Labor Code, you must
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forthwith comply with such provisions at this Permit shall W deemed revoked.
CONSTRUCTION LENDING AGENCY
I harcby affirm that mere is • mnsvuctinn Immo ng.,mey I'or Me performance of
Ne work for which this permit Is Wood (Sec. 3097, Civ. C.)
Undoes Name
Lender's Address
I anify that 1 have read this application and shote that the shove information is
trona. 1 agree to comply with all city and county on inarovs and state laws totaling to
building construction, and hereby autharim represcntstives of this city to enter upon tie
anus -mentioned property for iapection purposes.
(We) agree to ave. indemnify and Yetis harmless the City of Cupertino gout
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liabilida, judgments, costs and expen= which may in any way oast against aid City
in consequence of the granting of this permit.
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON -POINT
Issued by: Date
SOURCE REGUL TIONS.
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Re -roofs Re -roofs
alum fApplicanVContrulor Doc
HAZARDOUS MATERIALS DISCLOSURE
Type of Roof
Will to applicant or town, building occupant store or handle hmndous material
a defined by the Cupertino Municipal Code. Chapter 9.12. and the Health and Safety
WeSection 25532(a)?
❑Ya ANA
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 or future building occupant use equipment or devices which
Inrardnus oir contaminants As dcrined by the Bay Am Air Quality Management
all new materials for inspection.
Disvin7o
❑Ya
1 have mad Ne haerdaus maton.ls toquiremcnls under Chapter 6.95 of the Califor-
meHealth d Solely Cook,SCcna 25505,25533 end 25554.1 undostand that if the Wilding
d= not cuscntly have a Nano that itis my res'nouIilay to lily Ne uccupal of the
requiremntswhichmuo merpdorwinumccoreceNnca I
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Signature of Applicant Date
, q-0 -Oy
All roof coverings to be Class "B" or better
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ser or oath dsmt Data