05030142 CITY OF CUPERTINO "RAG
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BUILDING DIVISION PERMIT CONTR``A MR-JNFO ATIQiV
BUIL DING ADDRESS: ALCO CONSTRUCTION ""N%5030142
ER'S NAME: PERMIT ISSUE DATE
ONE: SANITARY MY CONTROL NO.
CHITECTYENGINEER: BUILDING PERMIT INFO
BO LDG O PLUMB MFCH
O O
ma'z LICENSED CONTRACTOR'S DECLARATION
1 hereby affirm that 1 am licensed under provisions of Chapter 9(commencing Job Description
with Sterling 70(X)oI'Divishm 3 of the Business and Pm1mitir Code,and my license Is
in full fora and effect
0z
Lknnc Clan IYSIGN.I .
, Dena CDECr
ARCHITECTS
DECLARATION
1 understand my plans a1Wi be trod as public rteordt
O
ted
Licensed arcia,Professional
e OWNER-BUUDER DECLARATION
a Y I hr Oso M.
that I fun exempt from the Contractor's License c Lew for the
O O fallowing moon.(Saito 703 1.5,Business and me.de oli Code:Any city or county
$ which requires;issuance.permit so re tires the siter.Impront mrsu,demolW,ri mash any tnavaare
Fly that heor itsensedruantto the lhovisio softheConich cnn'sLto icessigned Law(Chapter
<
(commencing
cing the Sq.Ft.Floor Area Valuation
that he is exempt
w W Section7000)and the
basis n 3 the al Busineeand Pnoon.An vi CNe)or
$ Net he b exempt thmfrom and Ole bub for the silagc0 exemption.Any violation of
Section 7031.5 by my applicant for a permit subjects the applicant to a civil penalty of 3 64JaV4 ez0 0 Occupancy e
not moa Nw an Ohundred dolWs($500). P YTYP
❑1,as owner of the property,Or my employees with were as their aria compensation, � I
will do the work,and thenructua is net intended a offered forsala(Sec.70/4.Bdgmaxi l �'
and Profesdon Code:The Ctmuctars Liesn Law don non apply m an ow'Mr of \ �' ; J Cq ITUl � ctions
papenywho yces,pdsarimpatsutheaprove who doessucmanotIhende oraffeedthrough Me I �.�,/ llownem.theWildin orided pr such improvementin nal lnteodWaaRead passage B,hander the avetnraimpmwmanngthat Is ediwitinot )ear ofmmPnatforon.pure - �
builder cath new thte burdan Of proving Nn he did not bWld or improve far purpnise of
ale/.
571,n Owner of the pmpmy am exclusively... ening with licensed management us J
construct the pmject(Sec.7044,Business and profeulam Code:)The Commogres Li-
cense Law does not apply to are owner of progeny who builM or Improves thereon.and,
who contracts for such projects with a eontracter(s)licensed punnnt to the Carmine.
License Law.
❑I am eaerypl u'n^M Date
See. ,B k P C far this ninon
at M
Date-
WORKERS aKER'S COMPENSATION DECLARATION
I hereby all under penalty of perjury one of use following declantimn:
haw end will maintain aCWfiaa of Consent w self-insure for WarkersCompen-
n.as provided fa by section 3700 of the Labor Cade,for the performance of the
rk for which this permit is issued.
❑1 bow and will maintain Workers Compensation Imemuce,as acquired by Seeuon
3700 of the Tabor Code,for Ra perfarmaae of the work fawhlch this permit is Issued.
My Workers Compensation insurance carrier and Policy number art:
Caller, Policy No.:
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(Tab shim recd Out hcomplevA)f IIB permit Isfaranc hundred OR.($100)
Or[am)
1 art ly that in the perfamana of the work for which this permit is issued.I ahsil rte
employ any person In any to cran sambemmeaubjecmto Ne Workcn'ComNotation
Lawesof califomie.Dau
APPliau44" 1114
nt
NOTICE TO APPUCAN7:i,afar making this Certificate of Exemption,you should -
become subject in the Worker's Compensation provisions of the labor Coal you mum
,JO forthwith comply with such provision or this permit shall be devoted revoked.
,zm CONSTRUCTION LENDING AGENCY
Iheaby efOrmthatthepo taaconwednn lending agency for Ne porfurmanm of
CYi ti the work fur which this permil Is bead(Sec.309'1.Civ.C.)
W Q Lenders Name
Z)z fender's Md.
U0 I anify that 1 haw postal this application and sum that the above informn)on b
IL^ colonel.1 agree in comply with sit city and county ordinances and sun laws relating to
Q SV^ building comractian,and hepoby authorize miaanutiws of this city to anter upon the
W 0,ne-menfloned property far inspection pugese3.
gL (We)agree w save,indemnify and kap harmleu Re City of Cupanino against
rA liabililles.judgments.cats andexprnse which may in any way acme against and City
fJ7 inconsegmnaorthelmlingofthispcmiL
�•m ANT UNDERSTANDS AND W LL COMPLY WITH ALL NON-POINT Issued by: Date
loKRecu� co „A �rli,�� Re-roofs
Sig of Appian onnaacer Dace
HAZARDOUS MATERIALS DISCLOSURE Type of Roof
Will the applicant or future building oauprenm amort or handle haxam us manriet
u donned by the Cupertino Munici al Code.Crisper 9.13,and the Health and Safety
ISd ,
s 3,enus3z(a)7 All roofs shall be inspected prior to any roofing material being installed.
❑Yu eWill thc applicant or future building Occupant use equipment ser devices which If a roof is installed without first obtaining an inspection,I agree to remove
haerdnn air cueuminanu sa darned by the Bay Area Air Quality Management all new materials for inspection.
n7❑YeaI hamead lCodc,he Stdrmss 25505.25533als rements 5334.1rderstand.95 of ifdw Califor-celth6SgfcyCadc,Sa0ou 0303.75577 and 25334.1 undcntsnd Nulf lite building cuncnthy ham a natant than II b mY reapomibilimy b notify the occupant of the
venuwhichmu be a p'orw'uuanceofaCcr iguin0 �mpmay Signature of Applicant Date
"� � All roof coverings to be Class"B"or better
raumhomad agend Date