02110125 CITY OF CUPERTINOa r:
BUILDING DIVISION PERMIT I CONTRACTORINFORMATIONi
g
BuRPIKA933rSETEVENS CREEK BLVD PERMITNI02110125
6
H$t:9FMITIG & SCHROMM, INC APPLICAT11N1S502`1Y2002
IONF.: SANITARY NO. / L / CONTROL NO.
ARCIIITfiCfIENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
�00 LICENSED CONTRACTOR'S DECLARATION b Description
�iF I hereby affirm that 1 am licensed under pNEW ELECT SIGOOSCIIprevisions of Chapter 9(commencing
with Section 70gg)of Division 3 of the Business and Profession Calc,and my lice
<� in lull force and effect. 2`L
ZOO�Z License las G q Lk.N
F Date�l-.� Contractor -
SO ECLA
1 understand my plans shall be used es public ar Js
a � Licensed ProfessionalOWNER-BUILDER DG CLARATION oil Ka<f I hereby affirm on 1 1. cacmpr from the Contractor's Licca.Law for Ibe
LOS:X 00 which
reason.(ScNun ID3 sum Business and Professions Calc:Any city or county
$� which its requires a issuance,also m e.nstruel,aafter.pplicant
improve,demolish permit t or repair any stmcmm
w'w priono itsedpu m requiree the
provisions of for sucCon Permit Licensle ae aw hapterm
£��<
that he 7 Xfctvsioof the Contractor ad Preclaw(Choptcr9 Affi3.4�1rbf7A1@A Valuation
y�$ (cat he is xem walltherefrom
7land the
Indian.3 n(thc egad exs )tion.Any sh Codc)lamon or
that ire H exempt them from and fee
buss for the alleged exemption.Any virealion of
not
ore than by wryapplicant forapmmil subjeca the applicenno ecivil penalty of PN-N Occupancy Type
..l more ma.Bveha.dmd dollars($sln)' 505 - FINAL ELECTRICAL
❑ Lotowner ,and the sumy,or my ,intended withwages utheiraele icks.B Business will dothework,and theswcartis noes License
s not apply
to
Business
end Professions Code:The Contractor'.License Lew does not apply lf nn owner of Required Inspections
Own em whoa,provi improves thereon,endwho atomssuch work oroffredthrough his
ownemployees,pmvior i pr such on is wemenaarenot intended moBered(orsale.I.
however,the building or improvement is wild within one year of completion,Nepose of
builder will have dw burden of proving thm he did not build or improve for purpose of
sale.).
❑1,as owner of the property,am exclusively contracting with licensed contractors to
construct the project(Sec.7BW,Business and Professions Code:)The Contractor.Li.
cense law does not apply to an owner of pmpony who builds or improves thereon,end,
who contracts for such projects with a contractor(s)licensed pursuant to the Commerce's
License law.
❑I am exempt antler Sec. B a P C for this reason
ncr
Data
WORKER'S COMPENSATION DECLARATION
I hereby affirm under Fertility of perjury one of the following declarations:
❑I have and will mention a Cenifcate of Consent to self insure for Worker'sComPcn-
sation,as provided for by Section 37))of the Islror Code,for the performance of the
work for which Nis permit is issued.
❑1 have and will maintain Worker's Compensation Insurance,as required by section
37M of Be labor Code,for the performance of the work for which this permit is issued.
My Worker's Compensation Inx rwr cc caner and Policy number art:
. Carrier: � - Policy No.: 229-aZ_
CEI CATE IFEX PTION FROM WORKERS'
COMPENSATION INSURANCE
(This section need nm becomPlmed little Permit is for one hundred dollars(BION)
or IessJ
I certify that in the performance of the work for which this permit is issued,l shall not
employ any person in any manner.as to income suhjecun the Workers'Compensation
Laws of California.out
Applicant
NOTICE TO APPLICANT:If,after making this Cendmate of Exemption,you should
become subject to the Worker's Compensation provisions or the Labor Colic,you must
'JOO forthwith comply with such Provisions or this permit shot]be deemed revoked.
q y CONSTRUCTION LENDING AGENCY
[–t I hereby affirm that them is a construction lending agency l or the performance of
ai > the work for which this Permit is issued(See.30y17,Civ.C.) t
aLender's Name
z Lender's Address
V Q 1 mnify that 1 have read this application and sate that the above information is f
W F correct.l agree to comply with all city and county ordinances and state laws relating to
O Vbuilding construction,and hereby aathorimmpmsenativcgOfthis City to enter upon the
W above mentioned property for inspection pulp....
(We)agree to save,indemnify and keep harmless the City of Cupertino against
CMM liabilities.judgments,costs and eapemea which may in any way sccree against said City
U z inconantmaecofthc nanting.fthispcono. '1 O ��
r APPLICANTS DSA D WILL C WITH ALL NON-POINT Issued by: Date �,`^ L
SOURCE RE TI
� 1117-01aZ Re-roofs
Stgm c of,714rdiCellituaiaor Dam
HAZARDOUS MATERIALS DISCLOSURE Type of Roof
Will the applicant or future building occupant store or handle hasindmis material
as defined by the Cupertino Municipal Code,Chapter 9,13,end the Hwilth and Safety
_LL.da, it.35533(x)7 All roofs shall be inspected prior to any roofing material being installed.
❑Yes ❑No
Will the applicant or future building occupant use equipment or devices which If a roof is installed without first obtaining an inspection, I agree to remove
emit hamtdoms air contamimons.defined by the Bay Area Air Quality Management all new materials for inspection.
District?
❑Yes C]No
I have mad the hmallous nationals requirements under Chapter 6,95 of the Califon-
me Drum MC�. ns35N15,Sin ast 3.55 4.1 ostly enecupoo,of ing
thedoe.nm cul, I it is m ms mrita tin rceupom of themquirem orm ace if, moroccirey. Signature of Applicant Date
409 11 20 o All roof coverings to be Class "B" or better
Owner ora orireJ agent Date