05030266 CITY OF COPERTINO e «t+syaw� L�Rat -ts"-Wi� `1.7^'n''�,'w'ti'-
BUILDING DIVISION PERMIT �� C"ONTRACTQR INFORMATION
BUILDING ADDRESS: NOVO CONSTRUCTION PERMITNG05030266
I R'S NAME: PERMIT ISSUE DAUB
PHONE: SANITARY ho. C NTROL NO.
ARCHI]ECUENGINEER: BUILDING PERMIT INFO
BLDGELECT PLUMB MECH
o E t�
il rep tp LICENSED CONTRACTOR'S DECLARATION lb Description
1 hereby affirm that I sac licensed under pooveers o
of Chapter 9(commencing
wish Smtlon]000)of Divhlon Sof No Busin wd Profeulum Code,and my Iiceneo Is
in full force and g5bLio TI--NON STRUCTURAL DEMO. (2-STORY BLDG) &
], Lkenec c Lk.11
L1. Date eanmemr /fN/o eo-setR.eM.�fa MODIFI /NEW WALLS
.9 Q ARCHnECrS DECLARATION
Y Cyt I wumnsand my planssIWI be used u public records
3 Licensed Professional
OWNEre exempt
DER DECLARATION
E ' 1 hereby.(Erns that I pm,Bump,from the ComuservorsCor License Law for doe
Oo
which
maws(Satlon]onstru Business and ve.Professions Corm:Any City or county
$ which reyuuea•permit us rnnwat,plug improve.de Permit
nr e 2 sig ed tatement
FZS^
prior miulueaace,pRont cultures o tho for suchhricute uccose caw Comment
(that he is licensed commencing
with Section
lithe provisions of the Comncwr,tJaanacssio(ChapterCode)
Sq.Ft.Floor Area Val•IF(1 1000
ags,Sig (ret he Is emptterefrmandM Ites for n 3 or
theBusiness
me pthon,My ud Profession
Code)or Y+
d— tion h h esempt Urnlran and Ne baso!ver Urz a11ejW escmpUon.My violation of
Section 7031.5 by any applicant for a permit subjects the applicant u a civil penalty of APN Number Occupancy Type
prep more than five hundred dollar(f300).
01,mowarruftliepmperty,mmyemployceawlthmrAnOckmlewmpemdon, 31621089 . 00
will dadoewars.and theswmmeiur'sLnded Lawdo(muk(Sat.]044,finer Of
and property
bus ldsor The Canuseuh License law drag or apply lf an owner of Required Inspections
own ertywho Wilds or improves thereon,andwho doe netchwmk himselfar his
own employees,theea,provided prsuchimprowmenuamnal year ntantled
foosebtheoun.lf.
however,the by the
ImpmvemantIshathe did oneyear of mproefor theose of
builder will have doe burden of proWnt that he did rot Wild or Mpmw far purpose of S,(/
sale.). �
❑1,a owner of the property,am exclusively contacting with licensed mntr cmn on
construct the pmjea(Sec.7044,Business and Profensians Code:)the Contractor's Li. Q^
come Law does not apply m an owner of property who Wilds or improve thereon,and V
who contracts for such pmjecu with a eonuucter(s)licensed pursuant to the Contractors'
Lme Law.
am esempl under Sec .B&P C fm this recon
er Dau
WORKER'S COMPENSATION DECLARATION
I hamby of irre under penalty of perjury arc of the following dalsommes:
❑thaw andw0 for
•CeNOpu of Consent'Code.surehe performance f u proh this
for by Section 3]00 of the IaWr Code,for the performace of doe
work for which thb permit it loved.
❑1 have sad will maintain Worker,Compensation Insurance,as required by Section
3700 of the Iabaf Code,for the performance of dm work for which this Permit is lased.
My Workers Ormpematlon Insurance carrier and Policy number are:
Cam(m Polity No.:
'CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(D1laseNm need nothammplered If the Permit Is fmanc hundred dollars(SIM)
comes.)
1 certify that in the Wrformm m of the work for which this Permit u iuued.I shall not
employ any person in any mmacr so as u become subject to the Worlo rs''Compewtian
Laws of California.Dau
Applicant
NOTICE TO APPLICANT:If,after making this Certnnm of Exemption,you should
become subject u the Worker's Compensation provision,of the fahm Cade,you must
.,O forthwith comply with such provision or this permit shall be deemed hawked.
z► CONSTRUCTION LENDING AGENCY
t—p Ihareby siTum that there is a construction lending agency for the perfarmsrcc of
a.> the wish for which tri,permit 0 issued(Sec.309].Civ.C.)
W Q Lenders Name
t�z, Leader'sAddrem
U O 1 ceNfy that I have mad this applicators sod sum Uw the above Information Is
Ip. cone0.I agree u comply with all city and comply ordinances and sum Is"nestles u a
0 SV' Wilding construction.and hereby Authorise repreanuuwa of this city he enter upon use
W abuve-mentioned property for inspection purposes.
(We)agree m save,Indemnify and keep bamleu the City of Cupertino against
TSA liabilities,judgmn:nu.costs and eapenaea which may in any way acme gdnsuaid City
t.)Z in eonsequenm of the taming of this permit.
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT Issued by: Date Z
SOURCEREGULATIO/�NS.
R'4+fl�,(3ActA.Ot 3(09/o'S Re-roofs
Signature of ApplicanUConuacmr Dau
HAZARDOUS MATERIALS DISCLOSURE Type of Roof
Will the applicant or future Wilding occupant some or handle huudous material
as dented by the Cupertino Municipal Code,Chapter 9.12,and the Health and Safety
e,Section 255370)7
r]Yea All roofs shall be inspected prior to any roofing material being installed.
u
Will the applicant or future building=upset use equipment or devices which If a roof is installed without firs[obtaining an inspection,I agree to remove
emit haeaMous air contaminants u dcOned by the Bay Area Air Quality Management all new materials for inspection.
0uhr 7
❑Yea �o
I have mad the hosNnus material,requirements underChapter 6.95 of doe Califor-
nlaHealth&SaWyCom.Sadao 25505.25533 son 25534,1 undcnund the If the building
Jap not currently haw a tenant,done it u my responsibility m notify Ua occupant of Ne
requirer�cnuwhichmuslW tpdoruinsuanceafa Ceruncam of Occupancy. Signature of Applicant Date
X A-to-Tr I^ "'Q4 All roof coverings to be Class"B"or better
Owner or avuurised agent Date