05010030 CITY OF CUPERI'INO
BUILDING DIVISION PERMIT CONTRe�C�'TORINFORMATION
BUILDING ADDRESS: J. T CONSTRUCTION PERMITNO05010030
OWNER'S NAME: PERMIT ISSUE DATE
ANNIE LE 01/05/2005
E: SANITARY NO. CONTROL NO.
408 2 72-4 570
ARCHITECT/ENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
C= (� 0
Sop LICENSED CONTRACTOR'S DECLARATION'
I bunchy Air,,. hot 1 am licensed under provisions Of Chapter 9(Commencing - Job Description
MMwith Section 7")of Division 3 of the Businca and Professions Code,and my license is
3 E infull mmaanderreC
Lken¢mea Lic.N REVISED FIELD CONDITIONS
Y 0 tf, -
J Dam Contractor
em� ARCHITECT'S DECLARATION
`e 1 understand my p4tu shall he it As Public records
h LL
Loomed Professional
C OWNER-BUILDER DECLARATION
Y 1 hereby affirm that 1 em exempt from the Comractoes License Law for the
00 following reason.(Section 7031.5,Business and profession Code:Any city or mumy
which requires a Permit to construct,site,improv,demolish.Or repair any Photons 80
S^ prior m its issuance.Alan requires the applicant forsoch permit to file a signed statement
4< that he is licensed pursuant o the provision of the Contractors License Law(Chapter 9 Sq.Ft.Floor Area Valuation
Ng (commencing with Section 7")of Division 3 of the B usinns and Professions Code)or
O that he 4 exempt therefrom and the bu4 for the alleged exemption.Any violation of
Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of 31\®2&A610er 0 0 Occupancy Type
m
Out arc man fore hundred dollars($30(l). P Y YP
❑I.As Owner of the property,or my employees with sego As their sole eompewtion,
will do the work,and me$wctum is or intended or offered far sale(Sec.7014,Business
and Professions Code:no Contractor's License Law dam not apply to an owner of Required Inspections
property who builds or Improves thereon,And who does such work himself or through his
own empleyeca,provided that such imprownwits arc not intended or ffered formic.If,
however.the building or improvement is sold within one year of completion.one owner.
builder will basso the burden of proving that he did not build or Improve for purpose oflu s
til.I. C'l
;who,
as owner of the property,am exclusively contracting with licensed contractors m
construct Ne project(Sec.7044.Business and Profevian Cotler)The Contractor's Li \a�
Law docs not apply to an owner of property who builds or improver thereon.and,
ontracts for such projects wife A eontractor(s)licensed pursuant tome Contnctdfs
se Law.
am exemptu ,B&P C for thiser Dov /WORKER'S COMPENSATION DECLARAT1 hereby affrmm under penalty of perjuy arc of tie following&lamiom:
banand will maintain a Certificate ofConsent tosel6inuto for Worker$Compen•n,As pmvided for by Boston 3700 Of the labor Code.far the Perforance of the
for which this permit is issue.
❑1 ban and will maintain Workces Compensation Inuranm,As required by Section
7700 of ma Labor Code.for the performance ofthe work for which this permit Is Wood. n
My Worker's Compensation Insurance carrier and Policy number am:
Carrier: Policy No,
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
rlb4saute neednothe compleed HOW Permit 4 rueane hundreddollar(SIM)
or leu)
I artily that in me performance or the work for which this Permit 4 hand,l shall not
employ any person in any Mannas As in become subject to IN Workere Compensation
Laws Of CAhun is Dae
Applicant ,
NOTICE TO APPLICANT:IL after making this Ce tricam of Exemption,you mould
baoMe$Object to the Worker's Compensation provisions of the labor Code,you must
O forthwith comply with such provision or this Permit shall M doomed revoked.
z� CONSTRUCTION LENDING AGENCY
I hereby affirm that mere Its cmusuuction lendingagencY for the performance of ..
Y. the work(inwhich this permit Is issued(Sue.31197,Civ.C.)
Y m•.
Q LcO&e.Name .
= z Under',Add
J 0 I certify that I have read this application and mlo that dte above information is -
y FCOMM,I agree to comply with all city and county ordinances and acro laws relating in
U building construction,and hereby uthorim representatives of this city to Color upon the
W ahovomentioned property for inspection purposes.
(We)a,mO to an,Ind amntry and keep harMlev the City of Cupertino.86.1
re, IlabilitW,judgmenv,emu and caresses which may in any way accrue againstaid City
J 7' in mrsouene or the Bruning of miapermil.
;iarim?
LICANTUN RST SAND WILL COMPLY WITH ALL NON-POINT Issued by:34te�
Dat
RCEREGvRe-roofs
lur A IicaHAZA DO DamHAZARDOUS MATERIALS $slow o6ORE Type Of ROOF
Will m ft Cupertinoant or murO bu4I Co e,Chanomrc2.and th huudaus maturfal
afety,efinedgoo by 25 Cupertino MuAdPal COM.Chapmr 9.12,and the Health and Selcty,QYu 35533(e)? Me All roofs shall be inspected prior to any roofing material being installed.
win me apPEmnt nr mlare banding nanp,nt a egaiPmem m uewi a seri 9n If a roof is installed without first obtaining an inspection,I agree to remove
hamdon air contaminants v da6ned by tie Bay Arta Air Quality Management all new materials for inspection.
��/
Dyes ftaaNu
I ham mad the hastNoVosmaterials mquiremanu under Chapter 6.95 of two Collier. ,
nm Health&Safety Com.Sccdun 25515,35533 And 25534.1 unmknes dmetlithe building
docs not currently how A Moan4 mat it is my waponihilby to ramify On,rccupa,of me
requirements whichm Pprto is$..or.CMOfCAW of Occupancy. Signature of Applicant Date
J' �D All roof coverings to be Class"B"or better
0 ei ora omrd agent Dam