05090083CITY OF CUPERTINO>*
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BUILDING DIVISION PETIT
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BUILDING ADDRESS:
PERMIT N0.0 5 0 9 0 0 8 3
OWNER'S NAME:
PI EMiC ISSUE DATE
E:
SANITARY 440. CONTROL NO.
ARCH=/ENGINEER:
BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
LICENSED CONTRACTOR'S DECLARATION
Job Description
I hereby affirm that I am Ilamed under provision of Chopmr 9 ( ommendng
p
with Sectionb )of Div Ian3of tho Butinen Pm{eah a J n mylkenmq
Infull forte and arced. VL V
TEMPORARY PERMIT (30 DAYS)
License elm Lk.N
Dam contractor
ORIG PERMIT 05080214 (OFFICES)
ARCHITECT'S DECLARATION
I understand my plan Nall W used as public records
Licensed Profmalonal
OWNER-BUnDER DECLARATION
1 hereby air. that I am exempt from the Contractors License Law for the
follhwing muon. (Section 7131.3, Business and Prof cam. Cade: Any city m county
which reyulms a Permit to cnnainou. slur, Improve, demolah. ar input, any atrucmm
prior to its issuance. alto requires the applicant forsuch permit to Ole a signed stammenl
that he is licensed pursuant to tier provisions of the Comma's License Law (Chapter 9
Sq. Ft. Floor Area
Valuation $0
(commencing with Section 70(,) of Division 3 of the Business and Profession Code) m
dust he is exempt therefrom and the buds for the alleged exemption. Any violation of
AIN Number
Occupancy Ty�
Section 703 LS by any applicant for a permit subjects, dw applicant to a cMI Penalty of
nm tome thus five hundred dollsom(11501).
36901021.00
OI,aawnerofthepmpeny,mmywploycewithwageutheirwleemmpan on,
'
Required Inspections
es q p
will dodo wok, and meatructum is not intended oroRered fnnale(Sm.7044, Bumset,
Profeuimu License Lew do
and aorn
Coda: The Oanun not apply m an owner of
property who Wilds or improves demon, and who dors such work himself w though his
not leaded mortemd formic. IC
awn employee, provided thatmuch fit is mid within
a the building arImProvementdshaltwithinot year of amowfir, me,eose
of
builder halo have to burden of proving that he did not bWm or improve fm purpose of
Mader
uk.).
/3
O 1. u owner of the property. sm exclusively contracting with EeoseE mntncmn to
/O�\•
consumer lime project (See. 7044, Business and Professions Cade:) The Comnnds U.
cone Lew don not apply to an owner of property who builds or improve theater. and,
who contracts for such pwjems with a contactor(s) licensed puraunt M the COnummors
License Law.
O lameameptunder Sec. ,BkPCfarthismuon
Owner Data
WORKER'S COMPENSATION DECLARATION
1 hereby affmm under partially of perjury an of the following decluation:
1 Is and witl maintain aCenlOem of Cancntmself4mu a for Workers Camper
utor. u Provided for by Section 3700 of the labor Code. fm the Performance of the
wok for which this Permit is issued.
❑ I have and will maintain Warkefa compemNon Imurance. at Rquimd by Sectian
)700 of the Labor Clads. for the performance of the were for which this permit is issued.
My Wa a Cam netian 1 nm ca cr had Polity
Caller r I Polity _
CERTIFICATE OF EXEMPTION FROM WORKS
COMPENSATI NINSURANCE
(Thds sadec need not becurepumd If the pmmitdsforme, hundred dollars (SIM)
fir bass)
1 cenify that in the performance of the wok for which this permit Is issued. l shall net
employ any person In hay mwnr an as to bSmme, subject to Um Worens CompeM1Ltan
Laws of Celifomia. Data
Applicant
NOTICE TO APPLICANT: If. after making this Certificate of Exemption, you should
become subject to the Workers Cmmpcmation provisions or the Labor Code, you must
faMwith comply with such provision or Nis permit shall be dimmed mated.
CONSTRUCTION LENDING AGENCY
1 hereby, airum thin then Its co swninn tendingagency for the Performance of
the wok for which this permit 4 toned (Son. 7097. Civ. C.)
'
Lenders Name
lender, Addmu
1 certify that l haw read this application used sum that the above Information is
correct. I sgra to comply with ail city and county ordinances and sok Laws misting to
building eanstmction. and hereby authodm mpmwnuliws of this city to enter upon the
ahow-mentioned properly for impaction purposes.
IWC) agree w Aw. Manually had kap hermteSe the City of Cupertino against
Itabilldes.jWgmems.cotts and expenses which may to my way accma agarol said City
a or Ne tm{pf this Permit.
in se"c"'mit.
D A DS AND WILL COMPLY WITH ALL ON. INT
Issued by: Date
CE RE NS. /�
A'
Re -roofs
Type of Roof
on or ApPlicandConuamor Da
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or round building acupanulore orbandle haeudous material
u dented by the Cupenina Municipal Code, Chapwr 9,13, and the Health and safety
code.0 3ssu(aI7
All roofs shall be inspected to any roofing material being installed.
Yes Na
prior
If a roof is installed without first obtaining an inspection, I agree to remove
Will the applicant o rectum building occupant use equipment a devices which
it haurdnm air conuminwu u defined by the Bay Am, Air Quality Management
all new materials for inspection.
imictT
Oyu
I hayc mW thehuurdnemaudads mqulmrwms under Chapwr 6.93 of the Califor•
SfcryCode,Section2370Y21111'25571.1u buil tog
urtenty how I c nam. the II25534.7 to rwUly the encu ant Inc
rundlyde
glall
whhW;n ' nc.mdra
Signature of Applicant Date
All roof coverings to be Class "B" or better
Own
for wlhoriwd agent DW
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