04070047CITY OFCUPERTINO
BUILDING DIVISION PERMIT
BUILDING ADDRESS:
HOWARD WRIGHT CONSTRUCTIO
PE.MTT 04070047
OWNER'S NAME:
PERMIT ISSUE DATE
SY
E
RARY 0 OL NO.
ARCHITECf7ENGINEER:
BUILDING PERMITINFO
BLDG ELECT PLUMB MECH
LICENSED CONTRACTORS DECLARATION
Job Description
1 homey arm that I am licensed under provisions of Chapter 9 (commencing
with Suctlin7 ) of Division 3 of Me BustProfesNom Code,andmylhenmis
i Lken'oocl aercemy� u�75
DEMO (E) COURT YARD
-
ARCHITECTS DECLARATION
1 U. tad Y pb blk records
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Lrocves anal ��—
1 OWNER -BUILDER DECLARATION
g 1 hereby affirm that I am exempt from fie Contractors License Law for Me
i following reason. (Socdun 71131.5. Business and Profeuium Code: My City or county
which m uims a rarmi m commoner, slur. improve, demollah. nr mpeir any structure
v prior in its issuance. also requires to applicant fearsuch permit to rile a signed moment
C that heulicensed punum,mtedprovisionsofthe ContractoreLicense law(Chapter 9
Sq. Ft. Floor Area
VaIDBt100
3 (commenang with Section 70(1 Of Division 3 of the Business and Professions Code)or
. that he is exempt therefrom and Me basis for Me alleged exemption. Any violation of
3 Mbil`D"ciro 0
Occupancy Type
Section 7031.5 by u0' applicant fora permit the applicant to s civil penalty of
nm more Nan five hundred dollars (SSW).
r '
❑ 1, as ower of Me Property, a my employes with "gas as Meir tole CompewMon,
'---^� Required.Inspections
',
will do the work and Mummer.. is not intended oroRered far sale (Sec. IDµ Business
Cade: The Camsores s License law dand apply a an owner of
and Pafesslons m
builds orimprove thereon, andwho doessuch work himself ordmugh his
propertywho beon
..employ=. provided Matsuch improvemcore m not Intended ora@sed formic 11.
�" r r , ,-
``/
however, the building or improvement is mid witore year ofcompteaon, Ne owner-
hin
,,, ;_� -_,
builder will the burden of proving that he did trot build or improve for purpose of
will have_.w✓
/. \
❑ I, u owner of the property, m exclusively canvassing with licensed cuntraaem to
The CroYs Li
cauuct the project (Sec. 7044. Busies and Professions Code) catru
ns
I
cave Law does not apply ro an owner of property who builds or improve lumen, and.
who contracts for such projects with a eomramor(O licensed pursuant M the Crontraetart
License law.
❑ 1 am exempt under Sec. . B & P C for this moon
Owner Data
WORKERS COMPENSATION DECLARATION
1 hereby affirm under pevlry of perjury oro of Me following dahmuns:
have and!will meinW n a CcNOcatn of Consentto self-mmon, for Worker-C—dxm-
anon. u provided for by Section 3700 of Me Labor Code, for Me performance of the
work fm which this permit is issued.
❑ I have and will maintain WOMV`3 Compensation Insurance, as required by Section
3700 of the Labor Cade, for the performance of Ne work for which this permit is Issues.
My Workers Commentralion Into mance cam .ad Policy number
li �Ilcy No.: t✓ I
CERTIFICATE OF M9511PTION FROM WORK IRS'
COMPENSATION INSURANCE
(Thio it. need Out M computed lfMe permit B formic hundredaaRata(SIW)
or task)
I certify that in the perlarmame Of On work for which this permit Is Issued, l shall not
employ any person In any manner an u on become subject to IN Workers Compensation
Law- of C.Iifmyi.. Date
Applicant
NOTICE TO APPLICANT: If, after making MIs Certinate of Exemption, you should
become subject m ther Workers compensation provisions of Me Labor Codc, you muss
.r, forthwith camply with such provisiom or this Permit Mall ne domed revoked.
CONSTRUCTION LENDING AGENCY
1 hereby affirm Mat Mere its construction lending agency for Me perfurmanco of
Me work for which Mu permit Is Wood (Sec. 3097, Clv. C.1
Lunda': Name
Lumber
lumr's Address
1 a dfy that I love read this apptuatiom and rete this Me -hove mformaMum Is
" cones l agree In comply with all city vW county ordinaries and tuns Iowa mladng to
Wilding eomuuction, and hereby auMarim rtprosentsfm of this city to enter upon the
pmpeny for Inspection purposes
-hovm (We) me to rove, indemnify and kith hay City of Cupen against
(We)
w Ks
which may In any way ecamc agelneuis City
,i it core ms of In
0
ence ofnW
in consequence permit.
this p
Aconsequence of the grooms UNDERSTANDS AND
" APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON -POINT
Issued by: Date
RCE REG TIO
Re -roofs
Type of Roof
plinmoSignature ofApcan Data
HAZARDOUS MATERIALS DISCLOSURE
Will the applicam or future Wilding occupant Dom or handle hamnious material
as defied by the Cupertino Municipal Code. Chapter 9.12. and the Health and Safety
Coda. Section 25532401. tIl+�
All roofs shall be inspected prior to any roofing material being installed.
❑Yes
If a roof is installed without first obtaining an inspection, I agree to remove
Will Me applicant of future building occupant use (MAPment or devices which
a neutrinos Cir co mea ivnu u de Intl by Me, Bay Arta Air Quality Management
all new materials for inspection.
Oct
❑Yes u
1 have road the hartnum matenalsrequirtmenu under Chapur6.95 of the Califar.
iia Heat" Safmy Codc,Sccdans 25505, 33533 and 25534.1 umdeutsnd thuif Me Wilding
dace not cwmnny have a umm. that it Is my responsibility to notify M occupant of M
wni he me P060 uancenfaCcrbruaua(Occuparcy.
Signature of Applicant Date
rire
All roof coverings to be Class "B" or better
Owner or anthomrb ahem Dau