03100047 CI TY OF CUPEWI'INO
BUILDING DIVISION PERMIT ON, INFORMATION gin:
BUILDING ADDRESS: PERMIT NO03100047
03100047
OWNER'S NAME: PERMIT ISSUE DATE
E: SANITARY NO. CONTROL NO.
ARCIIITECTIENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
0 (�
mO Z0 LICENSED CONTRACTOR'S DECLARATION Job Description
1 hereby affirm that l am licensed under provisions of Chapter 9(commencing p
•Ot1 with Section TOO))of Division 3 drthe Busircssa�Pru(cuium Code.antl rlignx is
0 Li full'kipgs and e(fen. ✓ )x
f,ClLic. 1 S
t y�Z Data GlI Central a /-f
,iJ ARCHITECPS DECLA 10 rp / 'M1ate
F reundmyplansshallbcusedaspv xaewNs
Licensed Pmfessinnel
10
OWNER BUILDER DECLARATION / IlIOj !
f I hereby affirm that I am exempt from the Contractor's License Law oh/ U `
00 following..an.(Section 7031.5,Business and Professions Cade:Any city or county
$(v which esquires a permit to cmnwct,cher,improve,demolish,ar rtput,any nruclure
prior to its issuance,also acquires the applicant for such permilmrilcesigned snlement
s C that he is licensed punu an,tobeprovisions ofthe Common's Unit aw(ChapterY Sq.Ft. FlorArelD Valuation
3 s (Cannealing with Scctiod7WO)rf Division 3of the Businessand Professions Codc)ser
that be Is exempt therefrom and the basis fm the alleged exemption.Any violation of
Section 1031.5 by any applicant for a permit subjects the applicant to a civil Penalty of APN Number Occupancy Type
not mom Nan raw hundred nonan(M). p y yp
01,uowneroflhepmpeny,mmycmployceawiBiw geaatheirsolecompenadon,
will do the work,and Ne structure is not intended oroffered forsele(Sec.1044,Business 101 - FOUNDF @did Inspections
and Profession Code:The Compact Lialue Law docs not apply to an Owner of
progeny who builds or improves thereon,and who does inch work himself or through his 103 — UFER
own employes,provided that such impro,emanu ax not intended or offered for nit,If, 104 — REBAR
however,the building or improvement Is sold within one sev of completion,the owner-
builderwillhawtheburdenofprovingBinhedidnotWildorimprove for purpose of 105 — ANCHOR BOLTS
ate.).
❑1,as owner of the property,am exclusively contracting with licensed contractors to 304 - ROUGH ELECTRICAL
convect the project(Sec.101C,Business and Professions Code:)no Contractor's Lt- 505 — FINAL ELECTRICAL
come law aloes not apply to an owner of property who builds or improves thereon.and,
who contracts forsuch pmjecu with a contractor(s)licensed pursuan to the Contractors 514 - FINAL PUBLIC WORKS
LN
rax=Opt aempt uncle Stt. _,Bh PCfnnhia rtaan
wnm. Dare ICP f1 r�3
•R5 OMPENSATION DECLARATION
1herebya Iml under penally of perjury me alum following dxlamaiin:
I than and will maintain a Certificate of Consent to self-imum for Workch Compcn- _
-lion,u provided for by Section 31W of dee Labor Code,for the performance of the
work for which this permit is issued.
❑I have and will maintain Worker's Compensation Instance,a required by SocOon
311 of the labor Code,for the performance of the work for which this permit is issued.
My Workers Compensation Inannce carrier and Policy number art:
Cartier. Policy No.: _
CERTIFICATE OF EKEM MON FROM WORK ERS'
COMPENSATION INSURANCE
rNissection need not be complmcd rthe Permit Is for one hundred dollars(SI W)
or less.)
1 certify,that in the perform race of her work for which this permlt u Issued,I shall not
employ any person inn nncr ten am ecom sob'ect tolh orkerr Cialicaatlan
Laws of California.D
Appli rat r
NOTJEW AFPL1 . [ making this Ccriifcau of Exemption,you should
become suhje a Worker' Compensation provisions arm Labor Cade,you must
O foot comply with such provisions or this Permit shall be deemed promised.
CONSTRUCTION LENDING AGENCY
1 hereby olllrme Nat there its comtnxtinn lending agency for are performamm of
Y de work for which this permit is inucd(Sec.3091,Civ,C.)
Q Lender's Name
U Lenders Addreu
0 I comfy that I hew read this application and sole that the Boom information is
Fcorrect.I agree to comply with all city and county Optimums and sate laws rotating to
�14 "moven entionuction,ed herebyemhop rposes. utives of this city reenter upon the
Mi ahovm(We)areial Progeny for inspectionnitakeeses.
ti (Wc)ipteetoave,indemnityandhousiddlessin
Be Cityof riCupcnst id City
h inconsequnceofthecoated expesuwhich may In anywayaccme gaunt aid City /
j Aconsequence of UNDERSTANDS
of this Permit. 'l
APPLICANT UNDERSTANDS AND WILL CO PLY WITH ALL NON-POINT Issued by: Date
SOURCE RECyuTIONS.
"a /7/as Re-roofs
2jgWre d6goiliefintiCtauxuatur ale
HAZARDOUS MATERIALS DISCLOSUR Type of Roof
Will Bicappliamm future building oecupam store or handl -rdous material
as defined by the Cupertino Municipal Code,Chapter 9.12.and the Health and Safety
Code, r-iYnzss3z(a)1 u,", - All roofs shall be inspected prior to any roofing material being installed.
Yes
Will the applicant or future building ottupant use equipment or devices which If a roof is installed without first obtaining an inspection,I agree to remove
it extortions air conuminants u dapped by the Day Arca Air Quality Management all new materials for inspection.
IWic11 �//
El Yes 095
1 have read the horurdous materials requirements under Chapter 6.95 of the Califon
nia Hcal"SafclyCodc.Sections 25515,25533 and 25534.1 understand Net if the Wilding
does not currently ham a tenan4 that it u my mapom(bility to and l'y tk creamer of be
requimmcntswhich mus asompronul sure.ragi90catrofoccupency. Signature of Applicant Date
wAll roof coverings to be Class"B" or better
Own uhac
ond ag g