04080195 CITY OF CUPERTINO a RR. ('
BUILDING DIV PERMIT CO�1TRA.CTOR N "'
BUILDING ADDRESS: PERMIT N MCLARNEY CONSTRUCTION Y 04080195
OWNER'S NAME: PERMIT ISSUE DATE
E: SANITARYO. iftOL NO.
lor 4082468900
ARCHITEC(ENGINEER: BUILDING PERMIT INFO
BLDG ELECF PLUMB MECH
0 0 0 0
upp LICENSED CONTRACTOR'S DECLARATION
1 bemby affirm that I am licensed under provisions of Chapter 9(commencing IOb SQ On
with Section 70(X0.(Division 3 of NC Bu' and Pr .wiyPsfC • my license is !i■p
in full rnrtevanae •cL srro //gT '� TI--VANILLA SHELL AL
Licenwi tae Lic.M
,gyp DamRCHITECPS DEC RION /�
< 1 ue e J m lana she eJ as public mcnrds NOV ,O 2004
Z G License c i al
y Oat I am BUILDER DECLARATION w��rr
<f I herchy oRtm Not 1 1. exempt from the Convector's Co License Law for the (DJ L
O
following mason. annitt Ire L5,Businessand mprve, emolih,or:Any city or county
K$_in which requires a e.aim re constrthe pion improve,demolish,i m repair any museutinamem
DING
FZy prior mits issuance,sive requires the applicant(.ranch permitm fileaxigneJ snmm.nl
< that he is licensed pursuant to the pmvislnesofthe Connector's License faw(Chapter9 Sq.Ft.Floor Area Va u hon
z�$ (c.mmcncing with Section 7000).(Division Sof On Businmsmd Professions Conic).,
.+ Nat he is exempt therefrom and the basis for the alleged ctemption.Any violation of
Section 7031.5 by any applicant for a permit subjects the applumt to a civil penalty of 3 6M3N f ;r0 0 Occupancy Type
..I more than five hundred dollen($500). -
0 L m owner of the property,m my employees with wages as their sole compensation,
will do the wodt and theamaclum is not inuMed proffered faraeie(Sec.7044,Busixu I
UTe
Re d Inspections
and Professiom Cade:Thu
Tire Contstorb Liaise Law dors not apply to an owner of q p
property who bu ilds or improves thereon,and who dues tach .,it himself.,through his
awn employees,provided that such improvements are ootinonded aro@red for ale.if.
however,the building or improvement is wild within one yew of complcdon,the owner.
Wilder
will have the burden of proving that he did Out Wild or improve for purpose or
sal..).
0 1.as owner of the property,am eaclusively contracting with licensed contractors to
construct the project(See.7044,Business and Professions Code:)The Conuacmr's Li-
cense Law docs not apply b an owner of property who Wilds or improves thereon,and
who contracts for such projects with a contractogs)licensed pursuant to the Contracture
Lic.nse La-
0 lwnaemptunder See. ,B&PCforthisrcaon
Owner --Date
WORKER'S COMPENSATION DECLARATION
I hereby affirm under penalty of perjury one of the following declarations:
have and will maintain a Ccnificam of Consent to wlf-insure for Workers Compere
tion,m provided for by Section 37W of the Labor Code,for the performance of be
work for which this permit is issued.
0 1 have and will maintain Workers Compensation Insmmw,as mquimd by Section
3700 of the labor Code.for Ne performance of the woks forwhich this permit is Caved.
My Wmkcrs Cnno a>m>don tom 'm and Policy number wc'
Comic V / t1 Policy No.: `L
C RTIFhATE OFEM Pf10N Ii&GA1aWORKERS'
COMPENSATION INSU CE
(Thisuction bond notheeompleted if the permit isformis hundred dollen($100)
lea.)
I cetify that in the performance of the work for which this permit is ban".l shall not
employ any pcnon in any manner m w to Wcomc subject to the Workers'Compcnadan
Laws of California.Dam
Applicant
NOTICE TO APPLICANT:IL after making this Certificate of Exemption,you should
become subject in the Workers Composition provisions of the labor Code,you must
Z forthwith comply with each provisions or this permit shall W deemed revoked.
z CONSTRUCTION LENDING AGENCY
[-ice I hereby affirm that then iso construction lending agency for the performance of
lY> the wink for which this permit is issued(Sec.3097.Co,C.)
Q Lenin's Namc
0.0. Z Lender's Addram
U Q 1 certify that 1 have mad this application and slam that the salve information is
F .orecL I agree to comply with all city and county ordinances and sum laws rotating to
�UWilding conven ction,and hereby mthodrepresentatives of this city m enter upon the
Lit above-mentioned property for inspection purposes.
G (W.)agree to save,indemnify and keep harmless the City of Cupertino against
rvF.t h liabilities,judgments,costs and expenses which may in any way accrue against mid City s
U ^ in S e
APPNT AND WILL COMPLY WITH ALL NON-POINT Issued by: Date
S LAT(
Re-roofs
08ignaufric or ApplicaroftriallilorDe
HAZARDOUS MATERIALS DIS OSURE Type of Roof
Will the applicant or future building occupant store or handle haodous material
�I fined by the Cupertino Municipal Code,Chapter 9.12,and the Health and Safety
Code.sec0ea,25532(a)T
E]yea, �J N//''u All roofs shall be inspected prior to any roofing material being installed.
Will the applicant or future Wilding occupant use equipment or devices which If a roof is installed without first obtaining an inspection,I agree to remove
t;tvvardnus
it contaminants as defined by the Bay Arca Air Quality Management all new materials for inspection.
is,
❑Yes No
1 have mad the hward ms materials requirements under Chapter 6.95 of the Califor.
at.Health&Safety Code,Sections 25505,25533 and 25534.1 Cosentino!thaz true Wilding
Jens not cure have..tcnanL Out it is my msponihiley w notity the cecupmt of the
require atbeMCI r ssuanceof.CenifittmnfOccvpancg Signature of Applicant - Date
nr a.maried agent Dam All roof coverings to be Class "B"or better