04030148TY OF CUPERTINO
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BUILDING DIVISION PERMIT
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DINGADDRUS:
SCOTT ARCHITECTURAL GRAPHI ERMIT"°04030148
1ilL
ER'S NAME:
PERMIT ISSUE DATECUPERTINO
NE:
SANITARY CONTROL NO.
(707)545-4512
ARCHITEC iENGINEER:
BUILDING PERMIT INFO
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LICENSED CONTRACTOR'S DECLARATION
Job Description
1 hereby affirm Nat 1 am licensed under previsions of Chapter 9 (commencing
with Section 7")ofDtvidon3o1' the Businesr and Professions Code. and my licensein
me effect,
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`REV SI`REV SI ION"39 EMA SIGN
License Chas Lic.p
Ll Class
Dam CamrecmrN—HflHSE
LY-NO NEW PERMIT
DECLARATION
As shall be
I undersand my plain shall be used as public DECLARATION
ORIG #03090032
Licensed Professional
OWNER-BUILDER DECLARATION
1 hereby affirm Nal I am exempt from the Contractors License Law for the
following reason. (Section 7831.5, Business and Professions Code: Any city or county
which requires a pemdl W construct, alter, Improve, demolish. of repair any structure
prior In its issuance, also requires the applicant forsuch permit to file a Signed statement
that he is licensed pursuant to the previsions of the Contrector's License Law (Chapter 9
Sq. Ft. Floor Area
Valuation .
(commencing with Section 7800) of Division 3 of On Business and Professions Cede) or
Nat he u exempt therefrom and the basis for the alleged emotions. Any Acted on or
0
APN Number
Occupancy Type
Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty lir
not mom Nan five hundred dollars (3500).
I,vowner of the propeny,mmy emplaycv wish wagessstheusale campensedon,
'. Required Inspections
.tilde the work end theaVYcture Is not interdedoraffered forsale(Sec. 7044, Business
and Predictions; Cost The Consciences License Law does set apply W an Owner or
property who builds or im proves Ihercon, end who does such work himself or through his
own employees. provided thassuch improvements are not intended "offered persalt, If.
however, the building or improvement is Bold within one year of completion, the owner.
builder will have the burden of proving that M did not Wild or improve for purpose of
sale.).
1, as owner of the property. am exclusively connecting with licensed mnuacWsx to
construct the project (See. 7044. Business and Professions Cade:) The Connaceri Lt-
cove law d upp1Y m an owner of property who bolds or improves thereon, and
co in for uch projects with acontnttor(a)Itcensed pursuant in the Contractor's❑
Who
l
mcm
1 exempt a der Se P for is rc n
OR
WO R'S MPENSA ON ECLARATI N
I hereby affirm under penalty of Pon of the following declarations:
1 have and will maintain a CeWfiram of Consent self-insum fur Workers Compen-
anion, an provided for by Section 3700 of the labor Code, for Ne performance of the
work for which this permit is issued.
I have and will maintain Worker's Compensation Insurance, as required by Section
3700 of the labor Code, for the performance of the work for which this permit is issued.
My Worker's Compensation Insurance carie and Policy number am:
Carver. Policy No.: _
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
mss section need not he completed irthe permit is forme, hundred dollars (SIM)
lir leu.)
I certify that in the performance of the work for which this permit is issued, l shall not
employ any Noon to any manner an as W honoree subject to the Workme Compensation
Laws of Califomta. Dam
t
Applicant
NOTICE TO APPLICANT: IL after making this Ccnifical= of Excmptian, you should
become subject It, the Workers Compensation previsions or the Labor Code, you must
forthwith comply with such provisions or this permit shall be doomed mvmked. '
CONSTRUCTION LENDING AGENCY
1 hereby talon Nat Ncrt is a Covwction lending agency for the perlormanee of
the work for which this permit is issued (Sec. 3097, Ctv. C.)
Lender's Name
Lenders Address
I certify that I have read this application and sum that the above infotmasiun is
Correct. I agree to comply with all city and county ondmances and state laws palating W
'
buildingcons tion, and hemby audorim represenetivrs of this city to enter upon the
above-mentiont property for Impaction purposes.
(We) sig ere, indemnify d keep harmless the City ofn Cupertino against
/Wo��
Jud Co. s
expert hmey to any way accrue against said City
molintl
inconsea
in consequ55 cc Nth, Holing oft'i it.
APPLIC, NO RSTANDS 1 COMPLY WI L NON-PO T
SO RC Rg UL ONS. }
Issued by: Date
Re-roofs
Type of Roof
�lL,�L�l��
Ilija of ApplicmVConuaet r D e
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future building occupant store or handle hazardous material
-
defined by the Cupertino Municipal Code. Chapter 9. 12. and flan Health and Safety
. Section 25532(a)+ _
All roofs shall be inspected to any roofing material being installed.
[:]Y. o
prior
If a roof is installed without first obtaining an inspection, I agree to remove
Will the applic t or Ntum building occupant use equipment or devices which
mit hazardous air contaminants as dclined by the Bay Arca Air Quality Management
all new materials for inspection.
District?
O yesNu
I he. mW the herardtnemamriais mquiremcnu under Chapmrd.95 Orion Califs,
nia HcalN&SafctyCCd,, Scc 8505.25533and25534Auncormodthnifthe building
doesoscurte fly hems a Nei it is my rcspovihiliry Wnotil'y occupant or Nc
req W;emen urchin 'arWbsaan=commfi
e=caeaf�o=- Cy.l,,.� y
Signature of Applicant Date
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All roof coverings to be Class "B" or better
Owner
or anlumn, ] cit Dac