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04020020 CITY OF TPERTINO G'© l �1CMl�. BUILDING DIVISION PERMIT _GTflR 0 6 PERMIT NO. BUILDING ADDRESS: 04020020 PERMIT ISSUE DAZE R'S NAME: SANITARY OL NO. NE: BUILDING PERMIT INFO ARCHITECT/ENGINEER: BLDG ELECT PLUMB MECH _00 LICENSED CONTRACTDR'S DECLARATION Job Description 0 affirm that 1 am licensed under provisions of Chow,9(commencing With Se1 heremon lIXKbyry of DdhhflCn Sof the Buamen;and Profession Code,m l my license is ^� 5Z force and effect. BAMBOO SPA License Clans tnNUam ITECSe F11Y L E® ARCDECLARATION 1 unticrsunJ my plena shall W useti u Public rccoNs MAR 2 4 2004 7yU ,G Licensed Professional OW MER-BUILDER DECLARATION 1 hereby vllirm Net I am exempt fmm the Contractors License Law for she �s.� �i 2 O following OMAN.(Section 7031.5,Business and Profmaion Code:Any city or County p(��1 D' which mquires a pclmil la eonswet.almr,improve,demnllah,Or mpair any swctum v ` FZ,- priorteimknumeo,almrequirestheapplicantforsuchpermittorileasignedstatement Valu hon G Ron.he is licensed pursuant to the previsions of the Contractor',License Law(Chapter 9 Sq.Ft.Floor Area $ (commencing with Section 7000)of Division Sof Me Business and ProfessionsCILL` Nal he u exam I themfrom and the huffs for Ne alleged wmarfuion.Any violation of Suction 7031.5 by my applicant for a permit aubjems the applicant a Civil penally Of 3 y3�-1V)rgl0erp p Occupancy Type not mom than five hundred dollars(SSW). ❑1.an owner of the property,Or my employees with wages As their sole compensation, will do the work and the owunts is not intended or offered forsale(Sec.7044,Busiws Required Inspections and Pmfessiuns Code:The Contractor's Liaise Law does oat apply to an owner of 9 P pnpenywho Wildsor improve thereon,andwhodoessuch work himselfor through his awn employees,provided thatsuch improvements are not intended uraffered forule.If. however,Ne building or improvement is sold within One year ofcomPMdOn,the ownr- builderwill Lave ON burden of proving Nal be did not Wild or Improve for purpose of sale.). 1,as Owner of the property.am exclusively contruting wit licensed conuacmrs to co tmet the pmjecl(Sec.7044,Business and Profusions Code:)The CanmaCtar'b U- cents Law docs not apply to an owner of property who Wilds or improves demon,and who con encu for such projects with a cmuwtor(s)licensed pursuant to the Convaclor's License law. i seer uam I ndar sec. :B&P C f thio reason SuhwtnAn D.te WORKER'S CO P MION ULI ILAKATI 1 hereby affirm under Penalty Of perjury ON of Ne following declamtiona: 71'31� have and will maintain a CeniBale of Conten 10"if-hosumfwWorker'sCompcn- ,u provided fm by Section 3700 of the Labor Code,far the performance of theLLI�for which this permit is issued.ban and will maintain Worker's Compensation Inmrance,u mquired by section of the Labor Code,(or the performance of the wok for which this permit is issued. orkers Compensauon Insurance carrier and Policy number am: er: Policy No.: CERTIFICATEOFEKEMPI70N FROM WORKERS' COMPENSATION INSURANCE (This section reed nothecomplcled if the permit is fimonc hundred doilars($10() or less) 1 certify that in Ne performance of the work for which this permit is issued.T shall not employ any person in any manner so as to become mbjecl to the Workers'Compensation Laws of California.Dam Applicant NOTICE TO APPLICANT:If,after making this Cenifscele of ExemPtim,you should become subject to the Worker's Compensation provisions of me Labor Codo,you must Z roMwilh comply with such provisions ter this permit shall be deemed revoked. ZO CONSTRUC ION LENDING AGENCY [�+ 1Wrehy.Moss mat mem I.A conswcto.icnding agency for me performance of ai> the work fur which this permit is issued(Sec.3097,Civ.C.) W Q l-mucea Name Z Lender's Addmn U 1 certify that 1 have read this application and state mal me dhow information I. (Y!�•'. come,I agree to comply with all city and county ordintnces and stem laws relating w p CS•.'1 building construction,and hereby authorise mpmunutiws of this city to enter upon the W shove-mentioned property for inspection purposes. (We)agme in now,indemnify and keep harmless the City of Cupertino against p) Liabilities,judgments,costs and expenses which may in any way acerae against mid City V'Z in consequence of the granting of this permit. i �•^ APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT Issued by: Date S RCE REG L ONS, l yy AC., I as 9 1 Re-roofs s' alum m(A li A ARDOr Da AZARDOUs MIATERIALS DISCLOSURE Type of Roof Will meapplicantor future Wilding cocupandSIOMr9,1m handle Health and defined by the Cupertino Municipal Cade,Chapter 9.12,and the Health and safety e,Section 25532(a)? All roofs shall be inspected prior to any roofing material being installed. ❑Yes VNO WEE the applicant or future building Occupant use equipment or devices which If a roof is installed without first obtaining an inspection,I agree[o remove 7IMCArdous air contaminants u defined by me Bay Arca Air Quality Management all new materials for inspection. cff ❑Yes Nu Ihavemadmehvardousmaterialsm uircmenuunderChapter6.95ofineCalifor- alm&SafnyCow.Samms25505.25533 and25534.1mch rstowthatifme building not currently haw a mon mat it is my mAperwhility M n0u1'y me occupant of theimmen w'ch LouIIMMetPrior10WS eoisCekficateof cupan - Signature of Applicant Date � 1cr 0r autho va sten, Q, All roof coverings to be Class"B"or better