02100065 CITY OF CUPERTINO " ,woe, +"' --
BUILDINGDIVISION PERMIT - CONTRACTORINFORMATION:•'--'
Bu 1210119DOE'sSTEVENS CREEK BLVD PERMITNO2100065
ffl"O&N BROTHERS ART & FRAMES APPLICATIf1`6SNU8T42002
ZONE: SANITARY NO./ / CONTROL NO.
ARCHITEC (ENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
=1
C0 LICENSED CONTRACTOR'S DECLARATION
U G 1 hereby aRrm that I me licensed new,yrovisinns of CM1apter Y(commencing SIGN Job Description
�]1y� wiNSccuonp}�xxpnfDivisinnJnfNCBusin yanJProcssinnsG c,andmyliccn is
< i.1.111. it
c LI /� ( �• REVERSE ILLUMINATED CHANNEL LETT RS
zo & Liccnso. �s Lia.g LXPIR ,.'.
C wDam Cumracmr ARCHITECT RATIONQ0j'anderstand used es p liercnrNsOuF L tensed Professionalt�0OWNER BUILDER DCCLARATION
1 hereby affirm that 1 am exempt from the Contractors License Law for the T�O O follow ng reason (Stu on 7031 5,Business and Pmfesa ons Code Any city fir countyawa�i which requires a mmit m construct,eller.improve,demolish,on repair any structure -- '�
prior to its issuance,also mi ores the applicant for such permit to file a signed statement
�s�s< that he is licensed pursuanuo The provisions of the Contractor's License Law(Chapter 9 Sq. Ft.Floor Area Valuation
F� (commencing with Section 7000)of Division 3 ofthe Business and Professions Code)tar
that he is exempt therefrom and the basis for the alleged exemption.Any violation of 35908018 . 00
Section 7031.5 by any applicant for a permit subjccb the applicant o a civil penalty of APN Number Occupancy Type
net mom than five hundred dollars(ssao). 101 — FOUNDATION
0 1,as owner of the propeny,or my employees with wages as their snle compensation,
will do the work.and Ne structhm is not intended or offered for sale(Sec.]044,Business 183
and Professions Code:The Contmcmrs License Law does not apply to an owner of 104 - REBAR Required Inspections
propeny who buildsor improves thereon,and who does such work himself or through his
own employees,provided that such impfovements are not brooded oroRered for sale.If, 105 — ANCHOR BOLTS
however,me building or impressment is sold within one year ofcompletion,me owner- 304 — ROUGH ELECTRICAL
builder will have the broom of proving that he did not build or improve for purpose of
sale') 505 - FINAL ELECTRICAL
01,as owner of the property,am exclusively contracting with licensed contractors to 514 - FINAL PUBLIC WORKS
construct the project(Sea 7044,Business and Profusions Code:)The Contractor's Li- .
cense Law does not apply to in owner of property who builds or improves Hereon,and
who contracts for such projects with a contractors)licensed pursuant to me Contractor's
License Law.
I am exempt under Sec. ,B&PC for this reason
wrier Dale
WORKER'S COMPENSATION DECLARATION
I hereby affirm under penalty of perjury one of Ne following declarations:
❑1 have and will maintain a Certificat of Consent to self loom for Workers Compere
sation,as provided for by Section 3700 of the Labor Code,for the performance of the
work for which This permit is issued.
0 1 have and will maintain Worker's Compensation Insurance,as required by Section
37f)of Ne Labor Code,for Ne rertormance of Ne work for which this permit is issued.
M/War er' Compensatimn Insurance carrier and Policy number am:
Mier. %kc, Policy No_:,./I/nZa_s�aD6b '7Q)
TIFICATE OF EXEMPTION FRW W ORKERS'
COMPENSATION INSURANCE
(This section need not be completed if the Fenno is for one hundred dollars(glfxp
in less.)
1 certify that in the performance of the work for which this permit is issued,I shall not
employ any peruse in any manner so as to become subject n the Workers'Compensation
Laws of California.Dam
Applicant
NOTICE TO APPLICANT:If,after making this Ceniticate of Exemption,you should
become subject to the Worker's Compensation provisions of the Labor Code,you must
OO forthwith comply with such provisions or this permil shall he deemed marked,
z CONSTRUCTION LENDING AGENCY
[r I hereby affirm that mere is a construction lending agency lint the performance of
Rai the work for which this permit is issued(Sec.3097,Civ.CJ
Q Lcndcr' Name ('1
z
U Lender'Is Address
T)0 certify that 1 have reel This application and slam IM1ar the shave inlirmmtiun is
V, (~ correct.l agree to comply with all city and county ordinances and state laws relating to
CU building construction,and hereby aulhorire representatives of this city m enter upon the
Uabove-mentioned property for inspection purposes.
14
(We)agree to save,indemnify and keep harmless the City of Cupertino against
y liabilities,judgments,costs and expenses which may in any way accrue against said City
V 2 in crosupwace of the granting of this permit.
�i APP ICANT UND RSTANDS AND WILL COMPLY WITH ALLA NON-POINT Issued by: Date
SO R E EGULATS. �I /O/� a
-�J / ZRe-roofs
Signature of ApplicaHAZA DO Da
HAZARDOUS MATERIALS DISCLOSURE Type of Roof
Will me applicant m future building e,Chapter
stare or handle Heaouusd Safety l
defined by the Cupenin Municipal Code,Chapter 9.12,and the Health and Safely
.do,Sec0am 25532(a)? All roofs shall be inspected prior to any roofing material being installed.
❑res
Will the applicant or future building occupant use equipment or devices which If a roof is installed without first obtaining an inspection,I agree to remove
emit hazardous air contaminants as defined by the Bay Arca Air Quality Management all new materials for inspection.
District?
Cl Yes "-fflNo
1 have mail the ha commis materials w,mor menu under Chapter 6.95 of the Califor-
niaHealth&SafetyCWe,Secu�ns25505,25533.d25534.1urdersmndthatiflhc building
dyes noterrecnoy have a tenant al it is my ,resprnuihility my he occupant of me
y,irc mnuwhich muslp�lMm normisimuccofa Cert atom capon y.
�/O OF Slgna[ure o pplicant Date
Owneror aamariz gens Dale All roof coverings to be Class "Be or better