04020128CITY OF CUPERTINO
: f"1,7777777-77777777777
R jNFORMA'I'
BUILDING DIVISION PERMIT
-NOVO
BUILOING ADDRESS:
CONSTRUCTION
PERMI "040201.28
OWNER'S NAME:
PERMIT ISSUE DATE
SNE:
SANITARY C NTROL NO,
ARCHITECT/ENGINEER:
BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
O O O D
LICENSED CONTRACTOR'S DECLARATION
OOSCTIP
Ib Description
1 bercby al@m Nat I am licensed under pmvieioes of Chapter 9 (commencing
.hisscetion" fDivision 3ofMeBusinessandP essions Code, and my license is
mmnmrcee n
p.,q
F',V/
_o2y
Licence CI B Lic. M
TI --SUITE #780 LEO
Dam _'1--Iy ^X/ Conwachur J
ARCHITF.CI'S DECLAR TION
I the
MAR - 3 2004
understand my plans shall used pe public ncnNa
Licensed Professional
OWNER -BUILDER DECLARATION
, n
1 hereby affirm I am exempts tiw fesnuns License Law for the
BUILDING
an Co
following moon. (Section 703 1.5, Bualtape and Professions Code: Any city or county
moo on
alcor. inlpmw, demolish. ri repair any
which sets i s a improve.
re eons
umment
Prior m its issuance, also nt to the tim applicant for such permit w file s eLiwd senmmem
u e. also Me
pursuant to the dm
MCI'scing
Sq. Ft. Floor Area
Valuanon
Code) or
(co it of Division 3 he usinesSLIttnYL1W(Chapterd)9
(commencing with of Division 3 of the Business and Profestca.
Anyn i
otorma7000)
Nn Is exe Motorman antl Ne aper far the alleged esemption. Any violation of
3 6A- IX1620er) 0.
O'ri l{^ s `lJfSraY
Occupancy e
P Y EYP
io 7 31.5 b for a pemtll subjects the appllunt w e civil penally of
Section 7031.3 by my
red dollars
not mom Nan fiw hundred tlollan (1500).
C] 1, As owner of the property, or my employees with wages as thehmle compensation,
Required Inspections
will do the work. and lheswcww isnot inwnded oraRered forsam(Sec. 7044, Business
Contractor's License Law docs not apply w an owner of
and Professions Code The ns
e 9 P
Property who builds m i mprows thereon, and who does such work himsel f or through his
own employees. provided that such improvements arc not inwnded woffered forsale IL
however. the building or improvement is wld within ane year ofcomplelion. the owner -
builder will have the burden of proving that he did not build or improve for purpose of
sam).
❑ I, As owner of the property, am exchahmly erne hating with licensed cona9Clars to
construct the prejxl (Sec. 7044. Business and Professions Code:) The Contractor's Li.
came law does not apply to an owner of property who Wilds or improves themon, and
who contracts for such projects wide a contsacwKU licensed pursuant in the Contractor's
License Law.
❑ I am uempt under See .B&PC for this mann
Owner Data
WORKERS COMPENSATION DECLARATION
1 hereby salon under penally of perjury oro of dee following declarations:
1 have and will maintain a Cemlicam of Consent N self-insum for Workers Compeer.
Milan, As provided for by Section 3700 of the Labor Code. for the performance of the
work for which Nis permit is issued.
Q 1 he. and will mairmi. Worker. Compensation Is..... as napored by SCCA..
3700 of the labor Code. for Ne performance of the work for which Nie permit is issued.
My Worke5'a Co Mmadan Insurance esmu sed Policy numkr ase:
a "N (slabs w Pan No.: ISZ—oY9�
ERTIFICATE OF EXEMPf7 WORKERS'
COMPENSATION INS ANCE
(Thr section need not hecompleted if the pemtitis foranc hundreddollars (SI00)
less.)
I certify that in the performance of the work for which this permit is issued, l shall not
employ any person In my mwnerso As to became subject to the Workers' Compensation
Laws of California. Dam
Applicant
NOTICE TO APPLICANT: If. after making this Cur ificam of Exemption, you should
become subject to the Worker. Compensation previsions of Ne labor Code, you must
foMwith comply with such provisions or this permit shall be deemed revoked.
CONSTRUCTION LENDING AGENCY
I hereby affirm that there is a ennalrection lending agency for the Performance of
'
dor work for which this permit is issued (Sec. 3097. Civ. C.)
lender's Name
Lender's Address
1 cenify that 1 have read this application and state that the above infamntiun is
aarecL 1 agree to comply with all city And county eminences and sense laws misting to
building construction, and hereby authorise representatives of this city to enter upon the
above-mentioned property for Inspection purposes.
' (Wc) agree to save, indemnify and keep harmless the City of Cupertino against
liabilities, judgments, costs and expenses which may in any way accmc against said City
in consequence of Ne grunting of this permit.
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON -POINT
Issued by: Date
SOURCE R ATIONS.
Re-roofs
Type of Roof
-27' Z -
t c pp rc Data
HAZARDOUS MATERIALS DISCLOSURE
Will rite applicant or town building accupantatom or handle hospices reamrod
as deaned by the C.Perina Municipal Cade, Chapter 9.13, end dee Health and Safety
'
Cede, Se❑cYCS 25532(a)7
All roofs shall be inspected prior to any roofing material being installed.
,m Ho
If a roof is installed without first obtaining an inspection, I agree to remove
Will Ne applicant or forum building =upon( use equipment ar devices which
n havamnus air commensals u de0ncd by ft Bay Awa Air Quality Managcmcnl
all new materials for inspection.
iswim7
❑Yeses
1 have mad the baaudousmamrials requirements under Chapmr6.95 offt Califor.
nia Health&Safety Codc, Secdons25505.25533 and 25534. I understand thmifthe Wilding
Jars no, cmmnlly haw a wmnl Nat it u my responsibility to notify the scup., of the
roqumern chmust`tx t is Ccof,ccnmmruppancy.
Z
Signature OfApplicant Date
All roof coverings to be Class "B" or better
Owsuns
rwtl agent Da,