05040014 CITY OF CUPERTINO
BUILDING DIVISION PERMIT MONTRACTOR INF�ORMATIAN:-
BUILDING ADDRESS: NOVO CONSTRUCTION PERMIrN 05040014
NER'S AM PERMIT 15611E DATE
NE: SANITARY DL NO.
ARCHITEC(ENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
LICENSED CONTRACTOR'S DECLARATION lob Description
1 bcmby Affirm Nm li
at 1 Acensed under provisions of chapter 9(commencing
ith Section 7000)ofDiNmon J of the Bualmas W ProfessionsComal,amy license V
Lk.Use- e.meRa 7�J1�,a TI--ADD 9 OFFICES/4 STORAGE RMS &
��•3 LICCnro ClusN
Dam F r'4 m�Contrmm `�C�,5'-C
0 ARCHTIECI'SDECLARATION RECONFIGUR 2 CONFERENC
I undemund my plans NallW used as public recardf TEMP PERMIT #05040083 �IALE°
G Licensed Professional
OWNER-BUILDER DECLARATION
1 hereby affirm 144 I Am exempt from Inc Conlnmor's License Law for the 2005
ca D following region.(Section 7fn 1.5.Business and Professions Cade:Any city or county _ .1
$ which requires a Permit to construct.after,improve.demolish.or repair Any abactum
pdorm Missuanee.alsomqulms the applicant forsuch Permlttofilc asignedgatemem
<
hunt he is licensed pursuant to the provisions of the Contractors Liam Law(Chapter 9 Sq.Ft. Floor Area n
D (commencing with Seniors 70M)of Division 3 of the Business and Professions Code)or
thin he 4 exempt themfrnm and the basis for the alleged exemption.Any violNon or 13 ILDINGM(M
Sermon 7031.5 by any applicant for a permit subjects the Applicant m a civil penally of APN Number Occupancy Type
not mom than five hundred dmWa($5001
❑Lssawncrofthepropmty,amyemployces with wages utheiranlecompensigh ,
will do the workmi the muctue is not imandedoralfined forsak(Sec.7014.Business 31621089 . 00 Required Inspections
Nd Prefasions Code:The Canuactor's LIa4e Law does rot apply b an awns,of q P
property who Wilda orimprom themon.end whodo4sah work himsalfar through his
own employees,provided that such Improvements ate net intended"offered for sale.If.
however.the building or improvement is said within one year ofmmpledon,the owner.
builder will Mw tbo Wrdan of proving that bo did nm WHO or improve fa purpose of
ask.).
❑1,a owner of she property am exclusively conaactin{with licensed mntrantore in
coustma lie pmjea(Sec.7044,Business and Profassions Code:)The Comratmr's Li.
cense law does not apply m an owner of propeny who Wflda or improv tiareon,and,
wbo contracts for such projects with aeonu Acmr(a)licensed pursuant to the Comnctur's
Licenm Law. '
❑I am exempt under Sea. ,B h P C for this reason
lwn,r DaeWORKER'S COMPENSATION DECLARATION1 hemby affirm under penalty of perjury one of tie following declarations:have and will maintain a CeNncate allotment m self4rume far Warker's Compen.
ass
n.as provided far by Section 3700 of t e Labor Cade.fm the performance of tiek far which this permit is issued.
have and will mainWn Workees Compensation Insumtm,4 requited by Section
0 of the labor Cade,for the performance of Rha work for which this permit is issued.
WarWYs Compensation Inuunna artim and Policy nu;��^'Q"ier. Policy No.:J V'f/A
CERTIFICATE OF ExEm ION FROM WORKERS' '
COMPENSATION INSURANCE
(Nh AsN.need mtbecompleted ift a permit is farm I undmddollan(SIM)
or lass.)
1 ar ify that in the perform a of the work for which this permit Is issued.I shall am
employ any person In my manner an as m become subject a the Workers'Compensmon
Laws of Califomb.Date
Applicant
NOTICE TO APPLICANT:IL after making this Cenincate of Exemption.You should
become Subject m the Worker's Compensation provisions of the labor Code,you mug
•,O forthwith comply with such provisimis or this permit shall be lamed mvnked.
z CONSTRUCTION LENDING AGENCY
[.v 4I hereby Affirm that thea Is construction lending ASency for the Performance of
(S•' the work For which this permit k Issued(Sec.3041 Civ.C.)
aQ Under'sName
7 z, Lender's Address
U Q I certify that 1 have read this appliadon and sae that the above Information 6
W correct 1 Agree m comply with all city and county ordim noes and Sum laws relating in
0 Wilding commuction,and hereby authadm representatives of this city to enter upon the
W above-mentioned Property fm impeLLan purposes.
(we)agree on saw,indemnify slid keep harmless the City of Cupertino Against
v.v y llabilhiesjedgmenu.casts and expenses which may in my way Acme Against mid City
V
in consequence of the granting of this Permit. '
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT Issued by: Date
SOURCE REGULATION
06tw �ckbc-- 6114loSj Re-roofs
Signature of ApplicanitContracmr Dam
HAZARDOUS MATERIALS DISCLOSURE Type of Roof
Will the applicant m future Wilding occupant awe Or handle haurdo4 material
As defined by the Cupertino Municipal Code.Chapter 9.11.and the Hcalth and Safety
ld-o:,
de.Section 3553i(a)7 All roofs shall be inspected prior to any roofing material being installed.
❑Ya �.fle ,
Will the applicant or future Wilding occupant use equipment or d.vices which If a roof is installed without first obtaining an inspection,I agree to remove
it haearda4 air cmtsmin fits u d.fiood by tae BAY Arca Air Quality Management all new materials for Inspection.
stria?
❑Yes o
I haw mad the huiM,wmwdalsrequiremenumd.tCMpwr6.95 ofdteCelifor.
HedA@ Safety Cad.,Sections 25505,25533 and 25534.1 undcn and ugif the Wilding
not cmmmly haw a enanL thg it 4.my responsibility m wdfy the occupant of tiw
ul�menu which mug be t prior m ssuance era ccrdnee of occupancy. Signature of Applicant Date
ncru autharizedts6 1 o� �( AAll roof coverings to be Class"B"or better
C