03030041CITY OF CUPERTINO r,�("7Lyr^gsf'�
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R M T
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BUILDING DIVISION PERMIT -
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BUILDING ADDRESS:
JSJ ELECTRIAL DISPLAY
PERMITNO. - _
ME:
459 INDUSTRIAL WY
PERMITLs A'
FIE
707747SS95
SANITARY 0 OLNO.
rENOINEER:
BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
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LICENSEDCON�AC�RnDECLARATION
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Job Description
barony afB.m Ne a fiians (commencing
wiMS tion7")of�DiHslon orthe Burnous anddl eashms ,andmn licenRu
in tul� fo.ce
aq�vrt �Idc a
LccwC
SIGN
Date Gonlf'EC
AlECrS DEC IDN
' nticrnJ my plena. W aided d pup0�rtcnNs
wMail
APR 3 0 2003
Licensed Professional
OWNER-BUILDER DECLARATION
BUILDING
I hereby affirm that I am exempt from Ne CmnnclmY License Law for the
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following mann. (Section 713 1.5, Business and Pro(ualoes Code: Any city Of county
which require a permit to construct. alter. Improve, demolish, or repair any structure,
prior An its issuance. also requires the applicant for such pc.mit to file a signed statement
that he is licensed recreant to the provialoru of the Contractor's ¢mc LAw(Chapter 9
Sq. Ft. Floor Area
$6VelklU on
(commencing with Section 70110) or Division 3 of the But ness and Profusions Code) or
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that he is exempt therefrom and the buts for the alleged eaemptlon. Any violation of
d 71T 7 �j�7jAAtt1D{.
3 140Iytler 0 0
Occupancy Type
Section T031.5 by any applicant for a permit subjects Ne applicant to a civil penally of
not more Nan five hundred doll... ($500).
1 p y
❑ I, As owner of the pmpcny, or my employees with wages As their sole compensation,
101- FOUND Atl3dj&I d IDSpeCl10DS
will do the work. and the epuctum is not intended or offend forsale(See. 70M. Business
end Profession. Code: The Contri License Law doe not apply to an owner of
property, whobullds orimproves lhemon, and who doessuchworkhimselfor through his
103 UFER '
own employees, provided that.uch lmpmvemenu are not Intended maffered forule.If.
,
- .104
however, Ne building or Improvement Is said within one year of completion, Ne owner-
, — REBAR
builder will have Met burden of proving Nal he did not Wild or Improve for purpose of
105 — ANCHOR BOLTS
ulcJ.
❑ 1, a owner of the property, am uclualvcly contracting with licensed contractors to
304 — ROUGH ELECTRICAL
construct the pmjeci (Sec. 7044, Business and Professions Code:) The Contractor', Li.
- 505 — FINAL ELECTRICAL
cenR Law docs not apply to an owner of property who W lid. or Improves theman. and
who Contracts for such projects with a conwcmrfs) licensed pursuant o Me Contrano't
,514 —, FINAL PUBLIC WORKS
License Law.
m exempt under Sec. . B A P C for this tenon
Data
WORKER'S COMPENSATION DECLARATION
1 haRby affirm under penally of perjury one or tie following dRlanliom:
-
ve tad Will m.1muso a Certificate of Canrenl to salf- n... fm Worker'. Compan.
u provided for by Section 37M of de Labor Code, for the performance of the
,
or which this permit is issued.
ve and will maintain Woftfs Compensation Insurance, ss required by Section
.
30711f the Labor Code, (or Ne performance of Ne wmk lmw rN Nis Permit uiuued.
rker' Compo to ins 'cr and Poli/n/ 2
r. PoIIeY Na.:
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(Thu section need not W completed If the (crmlt H foronc Wmdnddollan (SIM)
m Icu)
1 certifY Net in Ne perfnrmentt aY the work for which this permit Is Issued, i Abell not
employ any person in any mNnerso see Irl become subject to the Worked eampenialion
Laws of Califomia. Data
Applicant
NOTICE TO APPLICANT: If. after making this Ocrificam of Exemption, you should
become ubjcetin Ne Worker's Compensation provisions or the Lebo Code, you must
fctudi comply with such provisions m this permit shall W deemed revoked.
CONSTRUCTION LENDING AGENCY
I hereby affirm that there Is. construction lending agency for the perfurmanceof
_
the work for which this perm', B Issued (Sec. 3097, Civ. C.)
Lenders Name
Lender's Address
1 modify that I have read this application and colic that the above Information is
comply with allcityand and sole laws relating to
buildingcoreeto
buildingcotione construction. and herebyemhon replunrdinamor
RtlRs of Nis chy menter upon the
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above- purposes.
nctl property, for Impactionnd
agree s. save. Indemnify entl keep harmless the
(We) keepI of Cupertino
(s
idagainst
ju y Ac City
tocaltles,judgmanu.casu and expenses which tory in anyway eccrine against aid City
in consequence of the ranting of this permit.
APP S AND WILL COMPLY WITH LL NON-POINT
Issued by: Date
SO CE
Re-roofs
Type of Roof
O
Si fAp an omnm9r Date
AZARDOUS MATE RIALS DISCLOSURE
WIII theeCuramm,or fuNR Wildingoccupantrare lir
Bred and the Hulthamaterial
the Cupertino Municipal Code. Chapter 9.12. roti the Heslth m0 SafetySoc
'
int 25532(.)?
All roofs shall be inspected to any roofing material being installed.
❑ Yu u
0 yes
prior
If a roof is installed without first obtaining an inspection, I agree to remove
. Will the Applicant or future Wilding occupant uR cyvipmul or devices which
It haxamous air comumi amu u defined by the Bay Arta Air Quality Management
all new materials for inspection.
lmict?
❑YC. U
l have Rad the haramous maenala requirements under Chapter 6.95ofthe Califor.
nia Heal" SafctyCodc.Saed=25505,25533 and 25534.1 understand thrir Ne Wilding
does oat cu a m til' my responslhliirymna"fy the occupant of Ne
Inc,` at 1 an °'``"°este° ""�
Signature of Applicant Date
All roof coverings to be Class "B" or better
nor 94,1jidriouni Date