03120063 CITY OF CUPERTINO _ _ �"s�-yi. �„.
BUILDING DIVISION PERMIT GOWN: RAZT, RA 0�����0�"
euaDwc ADDRESS: CONSTRUCTIVE BUILDING SVC, PINCND03120063
20300 STR177NS CREEK ST WD
O YNER'SNAME: PERMIT ISSUE DATE
DAY CASEBEER MADRID RATCHIET-DE23932 '3911.1 9777,
'EWE: SANITARY OL NO,
ARCHITP.CIYENGINEER: BUILDING PERMIT INFO
BLDG ELECTPLUMB MECH
0 0 0 0
Loo LICENSED CONTRACrOWS DECLARATION Job Description
f1Zi 1 bereby eM m[hat 1 am licensed under provisions of Chapmr 9(commencing
n< with Sued..70110).17 Division 3 of the Business a p mn; ylicenu is
in full fomeand effe VI --IN HOUSE USE ONLY
5 Licenx less Lk.i
nk„4 Dau ARCHITECTS DEC` NEW PERMIT ISSUED/ ORIG. 403120063
?H U I.micam ad my plans Mall be used as public march
3 C Licensed Pmfessionel
OWNER—BUILDER DECLARATION
1 hereby.(firm Net 11. exempt from the Combctors License Law for the
DO following reason.Permit
,703 1.5,Business and Professivas Cade:Any city or county
�ftii which rcqulras a permit m ennatneL alter imPnve,demolish.or repair any awnum '
poor an its issuance.aim requires the applicant for such permit o file a signed stsumem
that be is liccnxd pursuant to provisions of NC Contractor's License Law(Chapter 9 Sq.Ft. Floor Area Valuation
$ (commencing with Section 7000)of Division 3 of be Business and Professions Code)or
.- that he is exempt therefrom and the basis for du alleged exemption.Any violation of
Section 7031.5 by my applicant for•permit subjects the applicant to a civil penalty of APN Number Occupancy Type
not mom Nan five hundred dollars($500).
01,as owner of the property,or my employees with wages as their sole comptroller, 36901019 . 00
will do the work,and the structure Isnot intended oro@red fa ole,(Sm.7W.But=
and Profeuiom Code:The Contractors License Law does not apply to an owner of RCguired Inspections
propertywha bulldsorimpra as IMrcon,andwha doessuchwak himselfordtrough his C
awn employers,provided dolman improvements arc notinunded ora@red frrasle.if,
however,the building or improvement Ismael within arc or of completion.W owner. a _V \
builder will love Ne burden of proving that he did not Wild or improve far purpose of (�
sale.). J
❑1.as owner of the property am exclusively contracting with Restated commctots to
canstmct the project(Sec.7044.Business and Profassions Code:)The Conambra U� ` v
cense Law does not apply to an owner of property who Wilds or impmm thereon,and,
who contracts for such projects with aeonlneuKs)liamed panuanl an the Convector's
License Law. _
❑T am aempt under Sec .B&P C for this
Owner Data
WORKER'S COMPENSATION DECLARATION
1 hereby affirm under penalty of perjury one radius following declantlm e
❑Ihavemd will maintain a CmdficabafCon..tuulGimumfmWorkcrsCompen-
astion.as provided for by Section 37M of the Labor Cade,for she performance of the
wmk for which this pornil is issue&
have and will maintain Workers Compensation Imuran.,as required by Section
7'100 of the Labor Code,for the performance of the work forwhich this permit is Issue,
My Worker Pemati Marc rticnnd Poli r
Cartier Policy
CERTIFICATE GFEXEMP ION FROM ORKERS'
COMPENSATION INSURANCE
(Ebts senun need not becampleted Rthe permit is farmuhundmd dollen($1010
or len)
I eeni(y that in the performance of the work for which Nis permit is issued.I shall nm
employ any person in any manxrm as to become subject to[W Workers'Compensation
Laws of California.Data
Applicant
NOTICE TO APPLICANT.IL after making this Certificate of Eaemption,you Mould
become subject to the Worker's Compensation provisions of she Labor Code,you must
.JO fonbwiN comply with such provisions or this Permit shell be lamed nevokcd.
N CONSTRUCTION LENDING AGENCY
[r Ihereby affirm Net Nem is a coaswction lending agency for the performance of
CL r7 the work for which this permit is issued(Sec.3097,Civ.C.)
W Q Lenders None
z Lender's Address - ^
V 0 1 aAfy Net 1 ply iced this applicationando sou that the above m relating is -
ly carrca 1 agree to comply with all city and county ntatnanaa and able laws relating to
r'W inconstruction,and heNorinrepmsenu[im of Niscity ucnurupon da,O , abovcmentioned property forimpaction
purposes
jLia (We)agree to save.' emnify and kap harmless the City of Cupertino admin /
fq Iiab'n;Z Judgm deapensee which may in anywayxeme ageinnmid City /I
V 7 in consequc t n g of this permit. —
Fi APPL RS ILL COMPLY WITH ALL NON-POINT Issued by: Date
SOU S. r;n I,{^O
Sign I of pp`c UCantbctn, Data
Re-roofs
HAZARDOUS MATERIALS DISCLOSURE Type of Roof
WI dm applicant or future Wilding mcupmt sore or handle hanrdous material
as fined by the CupertinoFoam
al Code.Chapter 9.12,and Ne Ficelth and Safety
code,Section 25532(.)7 All roofs shall be inspected prior to any roofing material being installed.
Pres
Will me applicant oedding a aapam sat equipment or devices which
If a roof is installed without first obtaining an inspection,I agree to remove
emit hanrdous air canourrom pa&rjncd by the Bay Arca Air Quality Management all new materials for Inspection.
District? /r\J'tl/.,r`y,
❑Yes
�ca%wnam
nusmauriaismquimmenbunderCWpter6.95ofNcCalifar-
niaHdam25505.25533and25534.I.nM. ndthbifthe Wilding
Jars Nat ibis my rcspamihility u nndly Nc aeupmt of Nc
rcquir6rimWIouana.(aC.njfiatpor rorty. Signature of Applicant Date
W • (/
Owns r thoriv .Seal Date All roof coverings to be Class"B"or better