05050146 CITY OF CUPERTINO wl;�•y s t,&. .:a. ser s. s
BUILDING DIVISION PERMIT sCCSNfRACTQR II�TFQ tMATI,gWIT,
BUILDINOADORESS: PERMITN0.5050146
W NER'S NAME: PERMIT ISSUE DATE
ONE: SANITARY NO. CONTROL NO.
ARCHITECrIENGINEM: BUILDING PERMITINFO
BLDG ELECT eZZ 0 � PLUMS MECH
LS I�
rl 044 LICENSED CONTRACTOR'S DECLARATION - Job Description
1 hereby affirm that 1 am licensed muter prWane Iioof chapter 9(Commencing p
with SmUon 70(X))a(Dividan 3 of the Business and ProfessionsCods,and my license Is
^� In fall fore and effa
ucenm clea5 Lle.g 9 INTERIOR T. I . GAMESTOP/SECURITY GRILLE
Dam cmuamor 617 T ®LL/CASHWRAP/CARPET
ARCHITECT'S D5CLARATION
Ire eyydyEnli [
Lleeued 4 mine
On,NEm exempt
DECLARATION
<� I Wreso affirm Nat 1 1. ucmpl from the Conon Co License Law for de / 1UU5
p O following moon.(Sevum 7(1]1.3,Business m0 Prafusioas Code:Any<irY or county / -' L
g F which requires•permit to cansweL alley,hnpmve,demalah,or repo:'So me
_Ilan prior to its!mum=.also requires the applicant for such permit to fileaaigncdsw qnnz
<
that he a licensed perm'..'So the Provisions of the Canuacmrs U. se aw ten r Area Valu$t3(g12 8 0
(commencing with Section 7o00)of Division J of the Busineuand Profcssinm c
that be n,exempt therafront and the basis far the alleged marequ]: My viol n of
Section 7031.3 by any applicant far a permit subjects the appncam m a civil penally at
net marc then five hundred dollars($5o0L A bar pe
❑I.uownorof Nepmpeny,ormyemploycuwllhwguutheh Sole Compuadm, 32632054 . 00
will do 0m work,and the structure u not intended"offered forum(Sec.7044,Business
and Pmfmi.m Cade:The CanbacmYe License Law dace not apply m an owner or Required Inspections
property who bands or Impmvea NCM1V It,and who does such wart himself ar thl W gh his
own employees,provided thmsuch improvements arc notimm�ded aranered forsste,if.
hovevcA the building or Improvement is Sold within am year of Completion,the owner
builder will have the burden of proving that he did an,Wild or imprve for purpose of
Sale.).
O 1.u owner of the prepeny,am exclusively contracting with licensed Conuanorc in
eootmn the pmjem(Sec.7044,Business and Prefessimn Cade:)The Contractor's U.
Cease Taw does not apply to an owner of pmpany who Wires m iminews thereon.and
who concocts for such projects with a emwetor(s)licensed pursuant to the Contractors
License Law.
of.. n.pt under See .B S PC for NB mum
Data
W ORKERB COMPENSATION DECLARATION
1 hereby alarm under penalty of perjury one of Ne following declarations: _
1 have w(1lmdnWn aCeNOnmof Cementresell-imumforWurkeYSCompen-
sWon,u prevlded for by Secdon 37M of the IaWr Code.for vise Performance of do
work far which this permit Is issued
❑1 low and will malnWn Workees Conpenudon Inmrmce.as required by Section
3700 of No labor Code,far the performance of the work for which this permit is luued.
My Worker's Corpeuad.I.rimes and Policy number arc:
Grtkr. Policy No.:
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(Thissectlan need not W completed If de permit Isforam Wndrcd dollen($100)
or less,) ,
1 cenify that in the performance of the work rot which this permit a issued,I Nall no
employany person In my manner an ss m become Sobject to Ns Wormers'Compensation
1JW3 or Csii(orle.Dam?/,(,/R7^ -
Appliunt
NOTICE TO APPLICANT.H.—after ce. oamaking N4 erl0oen of Labor Code,you
,JObecome subject it Wart pro Connor is ervWom of 0.LaborCode•you mesal
forthwith comply with such provisions or thapermilshallWdeemW mored.
ti CONSTRUCTION LENDING AGENCY
[-+ far
whichthi Ne Nes aacoaswc.3M.ding agcmyfns the perfurmmeeu(
CYi the worm fur which Nla permit a lured(Soc.Jo9'1,Civ,C.),
1[7 Q Irndch Nuns
=1
Z Leader's Address
C)Q I certify that 1 haw mad this application atmd State that the above inrom&don is
D: Conant.I agree to comply with all city and county morasses and wen law rearing to
Q V building consmrcuon.and hereby auNodm rcprcsenWwS of this city to Cuba upon the
(37 shove-mentioned property for Wpemfan purposes
(We)agree to Sow,indemnity and keep harmless de City of Cupertino against
liaNpWu,judgments.coo and expenses which may in my way attnte&Saint said City
In
D m'+
APPLICANT UNDEence or the RSTANDSof Ihis AND WILL COMPLY WITH ALL NON-POINT Issued by: Date
SOU EREGUyATIO /
// � 1 ?Lid$^ Re-roofs
Signatu�ApplicmVCon etas Dwe
HAZARDOUS MATERIALS DISCLOSURE Type of Roof
Will the applicant or future building accupantdorc orhandle hmardoo mabdsi
as de0ned by the Cupertino Municipal Code.Chapter 9.11.and the Hce1N and Safety
secuon15531(a)7 � All roofs shall be inspected prior to any roofing material being installed.
❑Yu
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
it hanardnus air contaminants u defend by the Bay Am Air Quality Management all new materials for inspection.
redo?
❑Yrs g{i�
I have mad the hmrdm
as materials rcyuimmenta under Cha par 6.95 of me Cali fat.
anHcal"Safety Caine.Scnctn 25305,73333 and 24334,1 unbursmnd dm If dec Wilding
docs not currently haw•tenm4 Nat It IS my Misoasiblllry to mufy the nue pmt or rhe
mgoire wn'chmaaW pdormlasumeear Ccrulicton041"'111,
res cy Signature of Applicant Date
)� �f,
Owneroraulharimdagent TDaen All roof coverings to be Class rB"Or better