04070069 CITY OF CUPERTINO
BUILDING DIVISION PERMIT , CONTRACTOR INFU�IATI40N• .•:
BUILDINGADDRESS: B & sJ SPECIALTIES PERMIT"04070069
OWNER'S NAME: PERMIT ISSURDATE
BO
E: SANITARY NO. CONTROL NO.
(408) 225-9999,
ARCHITECT/ENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
0 0 0 0
+(OZ, LICENSED CONTRACTOR'S DECLARATION
1 hereby affirm shat I an licensed under pmvtY.m.1'Chaplor 9(commencing Job Description
with Section afOivision 3ofdw Busircaay Pmfrtssiom GOdC.arM myliccnse is
Limn mineq O J-fi r/ Qs ,j TI--2ND FL. ( REALTY OFFICE)
�P i License Clas c.
�p Date Coal.
QrQ ARCHfIECrSDE OEC R i j
sD 3 1 understand my Plans shall be uu sed publicinrd
ic co
;'yU QLicensed /
Licensed Professirnal
5 OWNER-BUILDER DECLARATION O
.e 1 hereby alum that I am exempt from the Coroncsors License law for the
00 following maarn.(Secrom 731.5,Bulinus and professions Cade:Any city or county
K$ which requires a Permit to cnnsuuct,eller,impmw,demonh,or repair any structure
h z y
Prior In its issuance.also inquires IW applicant for uch Permit to rile a signed statement
<
that the islicensed Pursuant aOn mvi.ioasrfOcCommoner U..LawChapter 9 Sq. FL Floor Area Valuation
(commencing with Section70110)of Division 3 afthe Business and Profusions CrMe)or
y $
Our he is exempt therefrom and the basis for On alleged ascription.Any violation of
not mom than fbya aappve plliiccan�(S�rmit subjects On applicant to a civil Penally of 3IAWN "erO0 Occupancy Type
❑I,asowmr of Ne PmPmY•of my employee with weguasuwir rile wmpewti.n,
wiltdothewwkandtheatnmumunetintandedwofferedforule(Sa.TkA,Businw Required Inspections
and Professions Cods,The Committees License Law dans not apply m an owner of q p
property who builds or i mpmvu Neaten,and who deea such work h imml f w through his -
own employes,provided that such impmamenu art oat intandd mrRearA fwsals,IL
however,Ne building.(impmromenn is sold within one year of completion,Ne owmr
builder will have she burden of proving Nat he did not Wild or improve for purpose of
sale.).
❑1,u owner of she prepeny,am utlusively convecting with licensed..in.1. ,
construct the Project(Sec.70M,Business and Profusions Cade:)The Convacmis Li. _
cense law dose not apply man owner of progeny who Wilds or improve then..,and
who cont aces for such projecu with a contractor(s)licamed pursuant to the Conuacmis
e law.
sin escmpi under Sa. ,B&P C fm Nis season
Owner Data
WORKER'S COMPENSATION DECLARATION
1 hereby affirm under Family of perjury arc of the following declensions: -
aw and will maintain.Certificate,of Consent to self-Insure for Worker'sCompcn-
n.as provided for by Section 37011 of the labor,Code,far On per(....of the
work for which this permit is issued.
❑1 have and will maintain Worker's Compensation Insurance,as required by Section
3700 of thc Labor Cods,for the performance of the work fm which this permit is issued.
My Worber's Compensation hommur a carrier and Policy number an:
Carrier: Policy No.:
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(That section need notbecomphat d if the permit Isforom hundred dollars($10h)
or less.) \
1 warily that in the",unin mance .Ic we r r which this permit is Issued.I shall at
cmfdoy any pdpostjp any .hA subjew to the Warkcre'Campcnaadon
Lawsof Cali eI
APPIt'tFFret,� 2
NOT'1001'O L after making Ois Ccnificalc of Eumpsion,you should ,
Wo. ambbmt m the Workers Compensation provisions of the Labor Code,you most
,J 0 forthwith comply with such prrvistam or this pdrmit shall W domed mvoked.
.Zi y CONSTRUCTION LENDING AGENCY
(-w 1 hcmhyoffirm that Nen is a construction lendingaptay mf the perfurmmnce.f
!Yi> the work far which this Permit is issued(See,3097,Civ,C.)
WQ Lenders Name
Z l<ndera Address
V O 1 carify that I have rind this application and sues Net Ne sow information Is
T7.F cOreeL I agree to comply with all city and county ordinances and state laws relaxing to
0 V building construction,and hereby auNwie,mpmsenWima of this city to toter upon 0m
W above-mentiomd progeny for inspection Pmpases
6. (Ws,)agree to sero.indemnify ad keep harmless the City of Cupertino against
rq liabilities,judgments.costs and mpense which may in any way secaue against mid City
V Z in comequencc of the granting of Nis permit.
ti APPLI ANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT Issued by:3 Date
�r//
S UREQUM j/
�dIA y/7�/
Re-roofs
Signewm of Applice (lawHAZARDO
HAZARDOUS MATERIALS DISCLOSURE Type of Roof
Will the applicant or furan Wilding eaupentso=9A or handle Health and
as defintd by the Cupertino Municipal Code,Chapter 9.11,and Js,Health and Safety
Code.Section 15532(a)? All roofs shall be inspected prior to any roofing material being installed.
❑Yes �Na
Will the applicant or fulum building oaupanl use equipment or devices which If a roof is installed without first obtaining an inspection,I agree to remove
harardaus air comsminants as dcrincd by us,Bay Mu Air Quality Management all new materials for inspection.
ict?
❑Yes No
I havc mss the harasdasma¢rialsrcquinmenu undcrChapwr 6.95 of IW Califor
nix Heslth&Safety Ca .S.25505,15533am12553C.lundcssuMdwiflW Wilding
does t ears, 0y havc•weans.Nat is u my mopmuibility m notify us,oauprnt aT Ns,
ON, ata.,wai must met rmisman¢nraccnifc a .0 Signature of Applicant Date
Owmwmaatharind&get to All roof coverings to be Class"B"or better