04090028- CITY OF CUPERTINO VW "" -
IiulLDfrvc Drvlslon PERMIT ° CONTRt�CxQ'�.2INF4}RMATIUNS
BUILDING ADDRESS: FLUID INDUSTRIAL SYSTEMS PERMITNO.D4090028
OWNER'S NAME: PERMIT JESUS DATE
Ahlk STEVENS C
E; SANITARY NO. CONTROL NO.
40
AR CHITECVENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
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LICENSED CONTRACTOR'S DECLARATION Job Description
�a 1 hemby affirm Nn 1 am licensed under provisions.r Chapter 9(commencing
with
Sccti.n)1111U)uf DiviaionJof the Busi and Professions Cotle.and I¢cnx is
imm�rhaeA [en S ? REVISION TO PERMIT 04060255
License
Dam comae u, REVISE VENTILATION SYSTEM
QQ❑7 4 CHIIELTSD LAR ION
a y 1 understand my plans shell W used as pis m records /9
3 Licensed Professional v'V
3 5 OWNER-BUILDER DECLARATION
9E I hereby affirm thus 1 1. exempt from dr Convectors License Law for the
EQ O O following mason, wits it 7(131.5,Business and w,de nm Code:Any city.,county \/v
ce which require a permit m construct,erten impmw,demolish,or repair any swaum
at're prior m its issuance,also requires the applicant for such permit m rile a signed statement
?6 that he is liccnxd pursuant to the previsions of to Contractor's Llconx Law(Chapter 9 Sq.Ft.Floor Area Valuation 000
� G (commencing with Section 71100)ofDivision 3 of the Business and Professions Code)or v
y that he is exempt therefrom and the basis for the elegcd exemption.Any violation of
Section 7031.5 by any applicant for a permitxbjects the applicant to a civil penally of APN Number Occupancy Type
not mare Nan fico hundred dollars(5500).
01,as owner of the properly,or my employees wit wages as their sole compensation, '32632050 . 00
will do the work,and the structure isnot intended Cramped for sato(Sec.7044,Business
and Profc ahme Code:The Canuacmr's License Law does oat apply Io an owner of Required Inspections
property w ho builds or im proves thereon.and who does such work himself or trough his
own employees,provided that such improvements ere not intended oroffered for sale.IL
however,to building or improvement is sold within one your of completion,to owner-
, buildu will have the burden of pmving that he did not build or improve for purpose of -
sale.).
❑1.an owner of to property,am exclusively contracting with licensed contractors to
construct tite project(Sec.71 ,Business and professions Cada)The Contractors Li-
com s law does not apply to an owner of property who Wilds or improv Lemon,and
who contracts for such projects with a courramm i)licensed incident to Om Contractor's
Lkense law.
1 em exempt antler See. .B d:P C for this main '
Owner Data
WORKER'S COMPENSATION DECLARATION
1 hemby affirm under penalty of perjury one of the following declarations:
1 haw and will maintain a Certificate of Consent m self-insure for Workers Compen.
.tion,ns provided for by Section 3700 of the Labor Corte.for the Performance of the
work for which this permit is issued.
❑I have and will maintain Worker's Compensafion Imuran,ss required by Section
3700.1'the Labor Code,for to performance of the work for which this permit is issued.
My Workers Compensation Insurance carrier and Polity number am: `L U
Carrier. C�'6 InJQMzas�^1r Polity No.: �saO0JUT t)
CERTIP EXEMPTION FR07ORKERY
COMPENSATIONINSU E
(Thu auction need not W completed if the permit Is for o.hundred 011.(SIMM)
less.)
1 ar ify that in the performance of to work for which this permit is issued,l shall not
employ any person in any manner so as to become subject o the Workets Compensation
Laws of California.Dam
Applicant -
NOTICE TO APPLICANT:if,after making this Certificate of Exemption,you should
become subject in the Worker's Compensation provisions of the labor Code,you must
Oforthwith comply with such provisions or this permit shall 4 deemed revoked.
Z y CONSTRUCTION LENDING AGENCY
[—i I hereby affirm that tea is a construction lending agency for the performance of
(x the work for which this permit is issued(Sec.3097.Civ.C.)
Lender's Name
Lender's Address t
U Q I comfy tat 1 have mad this application end stain that the shout informed..is
F coned 1 agree to comply with all city and county ordinances and sure laws relating 1.
0building construction,and hereby Isotherm representativ of this city m enter upon the
r G above-mentioned property for inspection PUTOWL
(We)agree Io save,indemnity and kap humless the City of Cupertino against
rA Iiabilltics,judgments,costs and expenses which may in any way weroe againstaaid City
U 7Rdir
nce of guarded,of this permit.
r� NT STANDS AND WILL COMPLY WITH ALL NON-POINT Issued by: Date
GU
Re-roofspplicam/Conuecmr DamHAZARDOUS MATERIALS DISCLOSURE Type of Roof
l me applicant or future building occupant store or handle havammus material
by the Cupertino Municipal Code.Chapter 9.12.and the Health and Safety
ons 255320)? All roofs shall be inspected prior to any roofing material being installed.
es �W.
l 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
ous air ci muminants as defined by the Bay Area Air Quality Management all new materials for inspection.
Council
C]Yes k.
1 have mad the biramous materials requirements under Chapter 6.95 of the Califs
nuH.INB:Smcq ,SeNum 25505.25533 mu1255J4.lunderaund teifte Wilding
docs not torten a a moan,tat it is my responsibility in notify the Wee Am of On
:qui men hie W elpdor CenlOc.uc (Occup Y. Signature of Applicant Date
xz
Owner.,yAIwmx.cd agent Dam All roof coverings to be Class "B"or better