04020039 CITY OF CUPERTINO ' ? sw �+ "• % *P 'j*'r' ' `"x" '' "
BUILDING DIVISION PERMIT CONTRA IT®R�NFUILMATION:
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BUILDING ADDRESS: PERMIT NOb 4 02 0 03 9
R'S NAME: PERMIT ISSUE DATE
ONE: SANITARY O. 2 NTROL NO.
ARCHITECT'/ENGINEER: BUILDING PERMIT INFO
BLDG EIRCT PLUMB MECH
�0z LICENSED CONTR R'S DECLARATION O O O
�' LeipJ7,l,�escri [ion
1 hereat affirm wt I em licensed r provisions of Chapter 9(mmmemin{ f_�� p
i wIN(cctUm 7IXp)of Division to Jw and Professions Code.and my license is ,
^< int eandcaecL eo
n1 me clan Gong per SIGN .
,e ARCHITECTS DF TION JUL472004
y I understood my plain shall be mintaxfaseliffm.,.ad,
ira.
Licensed ProfProfessionalionBU
OWNER-BUILDER DECLARATION
<S I hea o .(firm on 1 1. exempt from the Canuamh License Law for the
Oo followingauoa Permit
Ela L3,Businessand Pmfeuinns Code:Any City or county
$
which myuisa a permit m uirm eti¢lac,Impront mrse,demolishh Perlin or aper any rtmcua
F y pthmasli.n dce.nu agoire pmvisi ns.f .C.npct.1'm0leasigne(Ch.p int
that me cing wit pSection
esuam 700)of Division
iviam of of Comncar'a License Law(CMptm9 Sq.Ft. Floor Area Valuation
Ila lost ho is exempt Semf orn and
of hags f r the
the Business!ma a pt Profea¢i vl C sketur
i,on of
$ Set he u campy wacfrom and or bur for be cts me eumant W Any violation of
Schon 7O rf by tory applicant for•Permit subjects Ne applicant to a civil penalty of 3 MAwTlwfi 1`15, O O
not more Nen Ow hundred dallara(5300). 6O0 FFPP slllWkJ/!!YY r Occupancy Type
I,as owner offt property,ser my amployaa with wages M their sole compensation,
willeowwak,andwswmuaumtia=kdmancmdruaale(Sec.7W,B"rum Required Inspections
and Professional
Cade:The Committers Licence Law exam not apply a an owner of q p
propertywho butldsor Imp nae,wren,and whodoesauchworkhimselfor through his
awn employees,provided that each improvements are not Intended ransomed mrsale.If.
however.Ne building or improvement is sold within am year of)ompledon,the owner"
builder will Nva w burden of proving Nat he did not build or Improve for purpose of
role L
.a owner of the property.4m exclusively coev xdril with licensed..=in.in
itpatient(Sec.7044,Business and Professions Cade:)Tin Canusetafs U"
s notapply to anowner ofproperty who builds terImprovathereon.ane for such projects with aeontracmr(s)licensed puaant m w Connnnor's
r ,B&P C for this masonDamWORK COMPENSA DECLARATION
by aRnm under penalty of peri om of the following declarations:
will maintain a CeNOate orchestra to sclGivum for Worker's Compen"
anon,as proAdW for by Section 3700 of the tabor Cade.far the perfumes.of in,
work for which this permit is issued.
❑1 have and will maintain Worker's Compensation Nuance,as acquired by Section
3700 of the lxWr Code.for w perfmrnsm:. bs work for which this permit is issued.
My r Compensation Insurance author a d cy number are:
\ O
CERTIFICATECOMPENSATION
SATIO I EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(this action need nmW completed lithe,perealt Is fmmuclumdreddnll¢m(SIM)
or leas.)
1 certify that In the performance of the work for which this permit 4 ismed,l shall not
employ any Person in any manerso as a become subject to w Worked Compasmon
Laws of Chifomia.Dae
Applicant
NOTICE TO APPLICANT:If.after making this CeniBam of Exemption,you should
become subject in Ne Worker's Compensation provisions of the labor Cuda,you must
Q z forthwith comply with such prhvismas or this Permit shall be deemed nevoked.
„zy y CONSTRUCTION LENDING AGENCY t
Fn I hereby aRren that them is a construction ladingagency for w performance of
C the work,fur which this permit is Wood(Sec.3097,Civ.C.)
�W Lender's Name
.7 z Lender's Md.
O Q 1 molly that I have need this applicuihn and sum that the above;nfomNun I.
(~
correct 1 agree to comply with all city and county ordinances and sum laws miming in
0 building mvwction,and hereby authorize nepresenmiws of this city to enter uponw
W shove-mentioned property for inspection purposes.
0. (We)agme to save,indemnify and keep harmless w City of Cupertino against
V) liabilities,judgments.costs and expenses which may In any way acme against read City
U aZ in consegoenee of the gaming of this permit.
" APPLICANT UNOERST A WILL CO V ITH ALL NON-POINT Issued by: Dale
SOURCER G
Re-roofs
m of Applicxm/Co per Data
HAZARDOUS MATERIAL LOSURE Type of Roof
MI)w appliant ter future Wilding occupant mom m handle haardous material
ecBnM by the CupeNno Municipal Cod).Chapter 9.11.and the Health and Safety
smaon:ss3zf.)7 ,/// All roofs shall be inspected prior to any roofing material being installed.
❑Yes ANu
Will the applicant ter`r Future coarsing mv:apant as equipment or devices white If a roof is installed without first obtaining an inspection,I agree to remove
It heardons air contaminants a defined by the Bay Area Air Quality Management all new materials for inspection.
uln7
0Yes N
I hew soul the lmea rtes moo nia.23u.12M
der Chepmr6.95aF1hr C.I1fm.
this Faalth&Safety Code,Sm9ons 25N1I unJcaund lhuifthc Wilding
ems mt c they hawa tenant wt It y m notify Ile oceuPent of Neaquiamc wh;c Ipnormifiateofoccupancy. Signature of Applicant a
Date
caner m aainanacd agent Date All roof coverings to be Class"B"or better