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BUILDING DIVISION PERMIT
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BUILDING ADDRESS:
204nO qTRUP.Mq (-UK RT IM
NOVO CONSTRUCTION
11111N10 5020016
ER'SP E: NAM
PERMIT [SUE DAM
PHONE:
SANITARY NO. CONTROL NO.
(650)701-3.500
ARCHnECfIENGINEER:
BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
LICENSED CONTRACTOR'S DECLARATION
Job Description
I hereby affirm dui I an licensed under provision of Chapter 9 (commencing
with Section ]010) of Division Sof dse Business and Profusions Code, and my license Is
in fulllOAC and %q/ OZZ
INTERIOR T.I. NEW WALL/CEILING
License Lic.
Dam . Contgractor QJo f
LIGHT FIXTURES -GRD FLR SHELL
DECLARATION
DECLARATION
ARCHITECTS"Iused
I understand my pun Nall Ee used u public
Licensed Professional
OW NEm .pHR DECLARATION
axe License Law for IW
I Wreby .(Seer Net 11. exempt from the Connector's
7D alter. and Profession Code: Any Nry or roomy
following moon. Code:
emtim
sr t. alter. Improve, deor mash nrocture
which rtquis a a pcmn re sures
tel, t,
permit ed
primmits luused p alwrequlrn devism of for sackIermit Ip Oleatimedwumem
(commis licensed PSemmt mthe NeLiccnseLaw (C
Sq. FL Floor Area
Val"§g
he Business Code)
of Division euand Profession,AnyiCade) ter
(commencing with Section ]000) of Division
r sor he z nged
mut M ts exempt therefrom and the bash far rote alleged esunptim Any Nolatim of
APN NumberCe
ane e
y Typ
Section 7031.5 by any applicant far a permit subjects the applicant se a civil penalty of
not mom Nm Bw hundred dollars (MOO).
36901028.00
01,uownuofthepmpcnymmycmploywswihwagnsu Ne mleeompeneetion,
Required Inspections
will da the work end the suumue Is not Intended oroffereA forsale (Sec. 7044, Business
snd Profession Cock: The Conbacur's License Law don an, apply in an owner, of
pmpeny who builds or improve, Nem er, and who does such work h imself or through his
own employees, provided that such Improvement tie not Intended oroirmed for sale If.
however. the Wilding or improvement lamld within om yam of completion, to owner•
builder will have the Wrden of proving mut M did Out Wild or Improve for purpose of
ask.).
❑ 1, as owner of the property, am exclusively contracting with licensed conmacm s M
comamt tise project (Sec. 7714. Business and Professions Cade:) The CmtrAcWs Li.
cense law does not apply As an owner of property who Wilds or Improves Merton, and
who contracts for such projects Mm s conmacbr(s) licensed pursuant to the ConlaEtoes
.
Lice
am eeempt Sec.B&P C lm this moon
Dose.3a566
WORT E S COMPENSATION DECLARATION
1 hereby aMm under pcmlty, of perjury one of the fallowing decimations:
-
❑ I haw and will maintain! CertificateofCoruent m self.Insum for Workers Compen.
"tion, u providW for by Section 3707 of the labor Cade. for the performance of the
work for which this permit is issued.
❑ 1 have and will maintain Workers Compensation luurmce, as mquimd by Section
3700 or the lab"Code, for Ne performmtt of the work for which this permit is issued.
My Workers CCompeuetim Imentrum artier and Policy number art:
Center: ` < « Policy No.: _
CERTIFI( OF (EMMON FROM WORKERS'
OMPENSATION INSURANCE
(Thtsecdm wed mlbecumpleted time .it is for oro hundred dollars (SIM)
m ksa)
I certify Net In the performewe of the work for which this permit Is issued, I shall not
employ any person in any manner an M m become abject to the Worken'Compcnsnion
Laws of California. Date
Applicant
NOTICE TO APPLICANT: If, after making this Certificate of Exemption, you should
bccome subject to the Worker's Compeuaton provision of the U Wr Cade. you most
faMwim comply with such pmvil n o W Nu permit mail W deemed revoked.
CONSTRUCTION LENDING AGENCY
1 Weby afRrm that then is a contraction lending agency for the performance of
the work for which this permit is issued (See 3097, Civ. C.)
Lecke, Name
'
Lend,es Add=
1 certify Nu I haw read this applieadon and lute met me show InfortnNm is
comet. I agree to comply with alt city and county ordinances and sure laws elating to
Wilding contraction, and Wmby auNorire representatives of this city to costs upon the
ahove.mentiomd property for Infection Purpnes.
(We) agree to raw, indemnify and keep humins the City of Cupertino agent
liabilities, judgments, cow and aspersions which may In my may anew againt said City
Inemseguenc egnnOng of this Permit. '
APPLICA U ERSTANDs AND WI L C PLY WITH ALL NON -POINT
Issued by: Date
SOURCE G ATIONS,
Re -roofs
Type of Roof
.asn 3` %5 OS
Signuurt of pplicant Canuacser Dau
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HAZARDOUS MATERIALS DISCLOSURE
Will the applicant a future Wilding occupant seem or handle harardous material
A, dented by the, CuMnino Municipal Code, Chapter 9.12, and the Health and Safety
Scctm 25532(.)7
iF p Yes
All roofs shall be inspected prior to any roofing material being installed.
If a roof is installed without first obtaining an inspection, I agree to remove
Will the applicant or forum building Occupant use equipment or devises which
emit hassmous air contaminants udefined by Ne Bay Area Air Quality Management
all new materials for inspection.
Dixmicl7 V
❑Yes
I haw mW the husrdousmalerlalsequlmmenumdcrChapur6.95 of du Calif".
.is Hes • Sec tion 25505, 25533 25534.1 mdersund Nmlfthe Wilding
;y
Jae noI curcn h a enam Net It n nay se notify de accupmt of Nc
equiemOnu mum bR mel pd i Cenifeate of Ocapmry.�
/
Signature of Applicant Date
All roof coverings to be Class "B" or better
Owner
or authumtdagent new