05030279 CITY OF CUPERTINOxrna �nz^ra •'. s
BUILDING DIVISION PERMIT r CONTRACT0R41NFU MATIQN
BUILDING ADDRESS: PERMIT NO.
TRITON CONSTRUCTION CO. 05030279
OWNER'S NAME: PERMIT ISSURDA'1E
f UPERTTNO CITY r ENTRR ace
B: SANITARY O OL NO.
ARCHITECDENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMBMECH
�OG zz LICENSED CONTRACTOR'S DECLARATION loin Description
I hereby afOrm that 1 am licensed under provisions of Chipur 9(commenein{
with Section 7")ofDividon 3 ofthc Business and Rofassmns Cade and my license is
rue
in full force end cffact. '2 S 2 1/ J
z Lieanaecl I Lic.11 REVISION--IN HOUSE USE ONLY
CSDECr ON L0,0-24 NO NEW PERMIT ISSUED/ ORIG. #05010110
'pQ
ARCHITECTS ba
DECLARATION
�i cyy77 I understand my plane Stull he useJ as public records
;Q Licensed Professional
OWNER-BUILDER DECLARATION
I hemby affirm Net 1 am exempt form the Contnctar.License Law for the
a O following recon.(Sccdon 713 L5,Bu4naaa and Perforators Cale:Any city Of county
g li which requires a permit In croutrvet,alar.Improve,demol W,or repair MY urueture
polar to to issuance,also requires,the applicant forsuch permit to File a signed Statement
qqq < that nue.licensed p...nt ro the pm.lamnaof the contractors Luces,Law(Chapter 9 Sq.Ft.Floor Area Valuation$35
(commencing with Section 7000)of Division 3 of ted Businw and Profcesinns Court or
that ns ls uempt themfran and the bub for the alleged exemption.Any violation of
Section 7031.5 by any applicant for a permit subjects the applicant o a civil penalty of APN Number Occupancy Type
not mom than ave hundred dollen($500).
01,u owner of The property,of my employees with wages uduh mlc compenuRoo, 36901019 . 00
will do the work,and the sdmture is not intended or offered for sale(Sec.7044,Business Required Inspections
and Professions Code:The Comr.ctoes Liana law don e ns not apply m an owner of q P
property who build,or Implement dtemon,andwho dauahwork hlmselfor throes{h his w
ownemployess,provided thatsuch impoevemenusm not Intended anffemd ferule.If. C,
however,the Wilding or impmwment B mid within oa year of rompledon.the owner-
builder will have tite burden of proving Out he did not Wild Or Improve fee Purpose of
uk.). V r�
❑L as owner ofxj ct property,,Bexclusivelysinend contracting with licensed rontracmn to �V
construct the project(Sea in in Business and Preproperty
who Wild,
Code:)The Comommon.and. /
Ll-
conks osew coca not apply c us owner of property who Wilde or impanwa Contra and
who contracts for such prokcu whoacontramr(O licensed punuemmthe Conteamrs
License Lew.
❑I am exempt under Sec, .B&P Clonhh msson
Owner Dau
WORKER'S COMPENSATION DECLARATION
1 hereby affirm tends,penalty of perjury ore of One following declarnlou.
❑1 haw end will mainuln•CeniRna of Conum m self-Insure fm WorkeM1 Cmmpem
anion,u provided for by Section 370D of the LsWr Code,for the performance of the
work for which this permit Is issued.
❑1 have and will maintain Worker's Compensation Insurance,as,required by Section
3700 of the Labor Code,for the performance of the work for which this permit Is Issued.
My Workers Compensation Insurance carrier and PolityMod�uy,-Z�
Cartier: O'Wrli—FUND Polity No.:� �7
CERTIFICATE OF FXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(Thin union need tint W completed if 1W permit Is faone hundred dollnt41110f0
or leas.)
I certify that in the performance of the work for which this permit Is Wood.I shill not
employ any person in any mannenn for to become abject in the WoneraCompcns.don
Laws of California.Dau
Applicant
NOTICE To APPLICANT:If,after making this CenlFicate of Exemption,you should
become abject in the Worker.Compensation provisions of Ne Laha Code,you mut
.,O forthwith comply With such provisions or 01,permb shall W decreed revoked.
r� CONSTRUCTION LENDING AGENCY
Fr I thereby affvm Nn Obert its constorminn land!,agency for that Performance of
12;> dte.,it for which rete permit I.issued(Sec.3(197,civ.C.)
W�Q Lender.Nance
=z Lenders Address
U O I anify Nn I have raid this application and.esu Nat the On.Information i.
It,F correct.I Ill 10 comply with all city and county ordinaue.and state laws relating In
0U Wilding construction,and hereby authorise representatives of this city to enter unto the
W Sithe-mentioned property for inspection purposes.
(We)agree to save,indemnify and keep harmless the City of Cupertino against
a..can liabilities,judgments.cuts and expenses which may,in any way accrue against amid City
U rte-7 In consequence of the granting of this permit
APPLICANT UNDERSTANDS AND WILL COMPLY WITH A NOWPOINf Issued by:9 Date
SOURCE REOUIsATI NS
y9" Re-roofs
Signature of ApP V antra1 Dow
NAZAR US MATERIALS DISCLOSURE Type of Roof .
WIII gat applicant or future Wilding occupanutoreor handle Iwordou.material
u dented by the Cupertino Municipal Cale.Chapter 9.12,and the Health and Safety
Code,Section 25532(.)7 m,Nt,� All roofs shall be inspected prior to any roofing material being installed.
OYcs
If a roof is installed without
WIII the applicant or future building Occupant use equipment or devices which . first obtaining an inspection,I agree to remove
IO huurdnua air contaminants as darned by the Be,Arca All Quality Management all new materials for inspection.
District? �'/
❑Yes you
I have mid dR hanrdou.materials requirements under Chapter 6,95 of the Califor.
lila Health k Safety Cade,Seed.25.3)5.25533 and 25534.1 undemand due Ifdn Wilding
does not curmndy haw a m...I,then It is my m.pouibilhy in nndfy the ae.mor of du
myuirtmcnu ichm m bra an aafaCcrtif¢ateofQCPanc SignatureofApplicant Date
Owner or wftrired e z n� All roof coverings to be Class"B"or better