04110063CITY OF CUPERTINO
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BUILDING DIVISION PERT
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BUILDING ADDRESS: 1 -
PERMIT NO. ,
04110063
OWNER'S NAM
PERMIT ISSUE DATE _
NE:
SANITARY OLNO. - -
BUIIDINGPERMITINFO_-
7AICHITEZZIENGINEER:
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BLDG ELECf_ PLUMB MECH
LICENSED CONTRACTOR'S DECLARATION
706 DeSCripti00Swti
I Mreby s(Brm Una 1 am Ikced der .visions of ChepWr 9leommeneing
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70010ofDivitlonJofthc Bust and PmfeadonsOne.madmylicenmR-,
Clas andellen Ll.g 7 A
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TI-LOADING DECK.__...___. --.-.•-
Dea coh
ARCH17ECrS DECL N
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I uMerWnJ my pisco shall he used u PuMI n c
License d•PmAfessional
OWNER-BUILDER DECLARATION
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i -- Ihereby affirm Net I em exempt (rem tho Connotes License law for that,
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o following reaaan. (Sudan 7031.5. Business and Profasslnns Cade: Any city or county
which rumps, a permit W cotsumL alter. improve. dunalleh. or repair: any suuctum
,
�+ prior to its lssuance.alao requires the applicant forsuch permil to Bk a signed statement
Comrmt.rk License Law(Chapter9
Sq. Ft. Floor Area .'--
< that he to licensed punew, to No prevision of the
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s(rommaneingwiNSwtion70W)ofDlvislon3af Nc Bvainmmd Profeuiom Cnda)ur
dui he Is exempt ticmfrmn and the bub far the alleged eumPU— MY rlolauon.f
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39A.DALTd,..#5VJ 0
1•V`L"PY
Occupancy Type
Section
e more Nm five h�Apal�veiisWnR subjects dm applicant m a civil Penalty of
b`YV
❑I.ssowmof Nepmpmy.mmYemPloymwiN.mudmGsolcompemd".
Required Inspections- -
willdotheworl.ma,16 swclum isnoimended or offered formula (Sec. 7014. Business
and-Pmfessiots Caae:.The Conummrs Umtue law it= ant apply in an owner of.
pmperlywhobWldsorimpmAesOwacon,andwho dmsuchwmk hlmsefforduough his.
Own employm, provided Nalsuch improvements an, nal intended erolfewd formal. If.
however, the building or improvement is sold within ane year o(completion, the owner.
builder will have the burden of proving dat he did ant build or Improve for purpose of
-
ss12,
❑ h as owner of the pmpeny, am exclusively contracting with liaised contractors in
construct the pmlect (see. 7014, Business and Pro essiou Code:) Tim Contrmmes LI-
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aenm law don not "ply toan owner ofpmperry who Wits or lmpsover demon. and.
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who contracts for such pmjuis with a conncmr(U licensed punuanl to the Contrmtora
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License Law.
❑lamFrSe ,Bk PC I. this mason
Data
Zan
DM B ON EC ATION
hereby&in oderpenally.!perjuryaneofthefollowingdwlararime,
thaw and will malnWnaCeNrrwmof Cemmntmmlf-insum fo Workers Compen-
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eamo, ms provided fm by Swddn 37M of the labor Code. far dm Performance of Ne
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work for which this permit is issmd
❑ 1 have and wilt maintain Workers Computation Insurance, as mquimd by Section
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3700.f Nclabor Code.fwdeperfarmmmof Ne fwwhich Nbpermitisi,,o
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MyWorkers Compensation lnsursmx carrier and Policy number am:
Cartier: Policy No.:-
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
Crass mctlon wed not Eccamplced lithe permit is froom hundred dollan($100)
'
or leu)
1 centfy Not in the performance of the work for which this permit is isswd, I shall not
employany person In an nrsoutobwomMb' Ire the Workers Compensation
we of Califo -
of Exemption,
I, r a csions
ET Rthe
dyou
mm
of de Ichor Coale, uam
jot m Wo Of
the Wort powtion
,
permit .
oMwi romPly wIN soh proviai.ns o this permit Nall M dnemed ranked.
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CONSTRUCTION cIONLENDINGAOENCY
y
Mrm start1 anby a11startClem b a construction lending agency for tied perfwnaree of
the work fm which this penult is lured (Sm. 7097. Civ. C.)
Q under. Name
Isndeh Mdmss
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z
Q I certify that I have mad dao applicadon and cum Nu the above informNon is-
F~' caned 1 agree to comply with all city and county ordinances and sum laws misting to
C.i building construction. and Manby wthodm mpmaenudAra of this airy to anter upon the
W aMve-mentioned Pmpony for inspection purposes.
gL (We) agree to not. mdcmnity and keep harmless the City of Cupertino against
y dabilities,judgments, costs and expenses which may to any way acme against said City
in c.rnrgmnee of the of this
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granting permit
APPLICANT UNDERSEA AND WI COMPLY WITH ALL NON-POINT
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Issued by: - Date
SOU REGU TIO
Re-roofs
Type of Roof
Apply AZARDOUS RIALS DISCLOSURE am
WIII Ne applicant o forum Wlldin& aavPant nom or Mndla hessrdow material
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0ned by the Cupertino Municipal Cade, Chapter 9.13. and the Health and Sarey
Section 25572(a)7
All roofs shall be inspected prior to any roofing material being installed.
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If a roof Is Installed without first Obtaining an inspection, I agree to remove
Will the applicant or fuwm Wilding Occupant use equipment at dewire which
colt humans air conundrums u deflud by the Bey Area Air Quality Mmnagement
all new materials for inspection.
W.6117
❑Yns �Nu
I have read Ne hax ohms mixed&], requirements under Chapter 6.95 of the Califor.
nb Health A, Safely ChM, Sections 25505.25577 and 25534.1 underwent dal if use Wilding
dos ant currently ham a Wheat, Net II is my to"mimidy to notify the occupant of the
requimmcntswhica1Mm .toin ceofaCcninnsmofOccupancy'
Signature ofApplicant Date
All roof coverings to be Class "B" or better
ow ,mho cos