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CITY OF CUPERTINOn
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BUILDING DIVISION PERMIT
CONTRACTOR INT"t.0 1v1ATI0i n ,r.
`n'', {' Y`F 1.•ii i i . 4.'"^kM'S'a� .4� :.
BUILDING ADDRESS:
US SHEET METAL
PBRMITNG04100166
NER'S NAME:
BOAS RRSTARTIANT
171 Q
PERMIT ISSUE DAM
1:7
NE:
SANITARY NO. CONTROL NO.
ARCHITEC (ENGINEER:
BUILDING PERMIT INFO
BLDG ELECT PLUMB MECN
LICENSED CONTRACTOR'S DECLARATION
lob Description
1 Wmby affirm that 1 sm licensed under provisions of Chapter 9 (commencing
with Section 70110) orDivision 7 of the Businessland Professional Code, and my license 4
in full fame aM.frat.
TI --INSTALL HOOD (TYPE 1)
License Class Lk.Is
Date Comranor
ARCHITECTS DECLARATION
I um mnuoul my plana goal W used as public remark;
Licensed Pmf esional
OWNER -BUILDER DECLARAT70N
I hereby affirm that I am exempt from NC Contractors License Law for the
fallowing mason. (Section 7071.5. Business and Professions Cade: Any city or county
which mqulrm a permit In cmrgrxL alter. Improve, doo m sdo 0, Inpelr any s rmunne
Prior on Its generate, also requires NC applicant for such Permit m file a signed salon n
that he is licensed pumunt to tho provisions of the ContractWS License Law (Chapmr9
Sq. Ft. Floor Area
Valuation
(commencing with Session 7000) of Division 7 of the Business ate Professions Code) or
Nal he Is exempt therefrom and me leu. for the alleged exemption. Any IoIW,on of
S42000
APN Number
Occupancy Type
Section 7031.5 by any applicant for a Permit mbjau the applicant to a civil porosity Or
oro mom Nan five hundred dmlua ($500)
0 1, as Owner of the property, o my employees wW "gas as Neb sole eompewtion,
Required Inspections
will do the wart• and the abuclure is not intended or offered for We (Ste. 7044, Business
and Professions Code Tlrc Connector, License Law don not apply on an Owner of
yees. pds m i d that such Impr and who de Out i nwmk himWror Nroujh his
ownproperty who
forsamtheOw.lr.
emprovemenuin ne ear
cdWomftrad
however. meor Improvement
however, Nebuimingmringmid athe didnet year M cempvfor the Owner-
Wilder will have the Wmcn of proving that he did vel build a Improve far purpose of
W.
L
I. licensed to
j
1� u Owner of the property am exclusively contracting wish conntcbn
construct the project (Sec. 7844, Business and professions Dade:) The Gomraem rg Li-
ttmLaw w does not apply m o in owner of property who builds Improves thereon, and
D
veno camnem Tot such projects with a eanlMor(s) licensed pursuant m be COntranoM1
who
�.
License IOW.
V
❑lam exempt un era See. ,BkPC (o Nb maven
w Dao y or
ORKER'S OOMPVNSAIIr ECLARATION
1 hereby affirm under Penalty of perjury one of the following declmtiona
I hew sad will main4N • CeNMte of Convent to self -mums for WormesCamPen-
ution. u provided for by Section 7700 of the Labor Cade, for dm performance or the
we' for which Nb permit Is Issued.
0 1 have and will maintain Worker's Compensation Insurance, u required by Section
3700 of me label Code. fur Ne performance of he work for which this permit is loved.
My Worker's Compensation lnsunmse eerier and Policy number sec:
Carrier. Polity No.:
CERTIFICATE OF EXEM PITON FROM WORKERS'
COMPENSATION INSURANCE
(This.ctinn need not be completed I f Ne permit Is far enc hundred dollars (SIM)
or less.)
I cattily Long In the performance of N. work for which this permit Is leaned, I shall not
employ any person in any Immerge As in become subject to the Work o x atlon
Laws of California. Dam
Applicant , "7n
NOTICE TO APPLICAp If, spur making t en�mal�f Exemption, you should
become subjen m Nc Wb :n's Compcnudon prOltlons a},Nc Lanor Cads, you mug
forthwith comply with such provisions or Nis permit shall be deemed revoked.
CONSTRUCTION LENDING AGENCY
1 hereby affirm that thane is a construction lending agency for the Performance of
the work for which this Permit Is issued (Sec. 7097, Civ, C.)
Iamdces Name
Undoes Address
1 easily Nal l owe glen and stem Nal the above information is
hiscity
ee with and and tum laws
bounce 1 apce m comply with all city and county omdm
or
r upon
teora of Nie city memcee upon she
buildingconstruction,on,and hereby wshon e
for Inspection purposes.
above- (We) agree m she City Of
egrets, sexes indemnify and trap
(s,
judgments, mayin against d City
in of thecooand expenses witch may In soy wry amus against Wd CIIY
or Negranting of this permit.
a
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON -POINT
A APPLICANT
Issued by: Date 2
SOURCE REGULATIO
Re -roofs
Type of Roof
Si{nuurt of Applicant/ nuaerm Dam
N ARDOUS MATERIALS DISC SURE
Will one applicant or (alae Wilding ottupont gore or handle onmous material
as defend by ant Cupertino Municipal Code. Chapter 9.13, and the HW N and Safety
Oct. Sado. 25532(x)7
EYus )jfNo
All roofs shall be inspected prior to any roofing material being installed.
If a roof is installed without first obtaining an inspection, I agree to remove
Will the applicant or future Wilding Occupant use equipment o Jevity which
mar to omnis air cemamimnu as defined by the Bay Ama Air Quality Management
all new materials for inspection.
Diavict7
OYea �Nu
I have mad the hvamommarerisis requirerxms under Chapter6.95 of Ne Csilfom
HcelN&SafmyCadc,Sa9ans25505.2737J and 2553d.l undcn4nd Nul(tix building
M.
does not CURCnJy have a tenant. Nil 114 my mapJmgnlllly m naJrY NC accYPanl of dx
mgnimmentswn agxmetpriar i ggear.cwrx,tear amy
Signature of Applicant Date
/Dates
All roof coverings to be Class "B" or better
Gwner or I.thdAxd agent rl