05030182 CITY OFCUPERTINO > +rz.t- ��A'%�' `°� x`°TM,
BUILDING DIVISION PERMIT i"CONTR GT�OR INF,ORMATI,O°,N•-`
BUILDING ADDRESS: """'05030182
ERMIT NOO5030182
OWNER'S NAME: PERMIT ISSUE DATE
PEET' COPPRR/STEVEN' S CREEK
E; SANITARY P03. ZONTROL NO.
ARCHOECT/ENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
�Ow LICENSED CONTRACTOR'S DECLARATION Job Description
1 MmbY AT.that 1 uWns oP
n licensed under provOof Chapter 9(rommcneing
with Section 7000)ofDivWon 3 or tie Business And Profession,Code.and my license la
in full tons and effcel.
5 ! V,
�: im..class C/O �^, 7 2 SIGN--EXTER. WALL & INTER. WALL
Dam� A'` RCH CA Ecua CONTRACTOR: R & K ELECTRIC. /{��R�
�i I undammod my plans Mail N used As public mcnms
3 (7 Licensed Pmfcuienal O� �Q
5g
OWNER-BUILDER DECLARATION
onsuaON
3 i 2 I hereby.farm Nat 1 A.1. .Burin faro Ne Pout c License Law for IN p
DD
following mown.(Semon 7mmunBualness andrve.delons Co de:Any city or county n(�
3
which mqulma&permit w�ir erthe oiler.hmProve,de ermit t m repair ed abactum /l
�^ Pdor wits inuanee,alau mquims the applicanlfonuch permluo file as@ned atsmmem vt
tam IMIMulicensedPuwanttotheProvlalonsofNOConmwwrsLeneLaw(ChaPm9 Sq.Ft.Floor Area Valuafyi0O_0J
(commencing with Section 7000)of Division 3 of the Business and Profession Code)or
Nal M la esampt themfmm and the bull for the sluiced eamnpdon.My violation of
Semon 7031.7 by airy applicant for a permit objects Ne applicant to a shot penally of APN Number Occupancy Type
not more than five hundred dollars($300).
❑I,as owner of the property,or my employees with wages as their sole comPMWIOM. 32632051 . 00
will do the work,and the suuctum is not intended or offered for sale(Sec.7041,Business Required Inspections
anProfessions Code:The ContmcmYs License Law doe,rwl apply wan er e ownof 9 P
property who Wildsor Improves Harem.cadwhodoes suchwork himselfor though his
own employees,provided Nu soh Improvements am trot Intended m Offered foram If.
hawewr,Ne MINUS.,Wpovemant Is mid within oro year of amPletine,the owner-
builder will have use human or pmong that M did aor build or Improve for purpose of
umJL
[]h as owner of the property,am exclusively cantraning with licensed contr&ewn to
construct 0e project(Sus.701,Business aed Profession Cade:)M Contracwrs U.
cene taw does not apply to an owner of property who Wilds or improves Nemun.and
who contracts for such projects with a eonu&nor(U licensed pouusm m the Cramose e's
License law.
❑I am eaampt under Sec. ,B h PC for this moon
venae Dam
WORKER'S COMPENSATION DECLARATION
1 hereby of ire under penally of perjury ane of the following declarations:
❑1 have end will Malcolm a Cemfrcatief Convent la selfdnsure fm WorkCeIComPm-
sstion,as provided for by Section 3700 of the labor Code,for the performance Of me
work for which this Permit s ismo t
❑1 have and will maintain Worker's Compensation Insurance,u required by Section
3700 of the Labor Cade,for the performance of Ne work forwhich this permit u issued. .
My Workefa Compewdon Inwnue canic,and Policy number am:
Carder. Policy No.:
CERTIFICATE OF EXEMPTION FROM WORKERS' '
COMPENSATION INSURANCE
(IBlasection need net Mcomplewd def the Permit is fmooehundmA dallan(5100)
or mss)
1 unify that in Ne Performance of the work for which this permit la issued.l shall nm
employ any person in my manners sswb em9j nt talo Vo ara(CompensNon
Laws of Californi am ^
Applicant � ase Og.
NOTICE TO A PLICANI!1�,after makinirthis CeniOam o -OMPlloq you should
become subject w de Workers Compensation provisions of talo Labor Code,you muss
Qforthwith comply with such povWons or this permit shall be domed revoked.
z tiCONSTRUCTION LENDING AGENCY
EI hereby alarm that them Is construction lending Agency for the performance of
> the work for which Nis permit is Issued(Sec.3097,Civ.C.)
GQ Lmdefs Name
Z)Z Unde's Addrm
U O 1 certify that 1 lave read this Application and sum that use&how infomtstiun is
{2v!'.. torten.I agree w comply with all city and county ordinances and mm laws misting At
0 building construction,and hereby authorio representatives of this city to color upon the
W aW.-mentioned Property for Inspection Purpoea
(We)agree to eve,mdcmnify and keep hatmless the City of CIPCnina Against
y liabitiuea judgments,cam and expenses which may In any my accrue,against Mid City
U 7 in eomequcnce of Ne Noting of this PKMML
r� APPLICANT UNDERSTANDS 0D ILL Ojt1PLY WnN ALL NON-POINT Issued by:91to�t�zw Date
SOURCE ULA S. ,/0
`� a-roofs
Signature OfAppl cocar Dem
HAZARDOUS MATFEIALantmom OSURE Type Of ROOF
WIII the Applicant Cprt n forum Mal Co e.Chapter
mom m ltsedm hnsmou material
As de0ned by the Cupertino Municipal Cade.Chapter 9.12.&M Use HCA1N and Safety
Cram.Semon 23332(.)7 All roofs shall be inspected prior to any roofing material being installed.
❑Yes
Will the,applicant at future building Occupant use equipment or devices which If a roof is installed without first obtaining an inspection,I agree to remove
emir haurdnus all conmminanm u de0ned by the Bay Area Air Quality Management all new materials for inspection.
DioiclT
❑Yca
IIIaw mad the Mramnmm&lod&b requirenlonu under Chaplord.93of No Glifon
nu HmlthASafety Code.9emons25505.25533od25534.iundermndthaif Ne building
dos not currently haw a tenant,that It is my responsibility w nmfY 1M occupant Of Ne
mwimnmmtwb .W Pdarwas afa acsmafaen SignatureofApplicant Date
g° 8
Owner onuthodmd 1& Dam All roof coverings to be Class"B"or better