04050042 CITY OF CUPERTINO
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BUILDING DIVISION PERMIT <,CO1�,TRACTQI2`IIVFORMr1.TI0 "r,,,:,
BUILDING ADDRESS: CUTTING EDGE CONSTRUCTION PERMIT N®4050042
OWNER'S NAME: PERMITLSSUEDATE
E: SANITARY NO, CONTROL NO.
IV
(426) 280-2625
ARCHITECT/ENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECHI
I� 0 0 0
�oo LICENSED CONTRACfO IDECLARATION
1 hO affirm mal 1 am tensed un r provisions of Chapter 9(commencing Job Description
wide wide Section )of Dlvision3ofine Bu and ProfevtiomC rld mylianse is
n< full to u cl'� 1
Limmx lora � L2. =P 0 a6 REVISION--HOOD/EXHAUST OUTLET
Dam II �Contriami NO NEW PERMIT ISSUED/ORIG. #03120084
retie J y nsN II ac pas ercc
3Q Licensed Prof 'Doll
OWNER-BUILDER DECLARATIO
I hereby affirm mut 1 am exempt form me Contractor's License Law for the
o O follnwing mason.(Sectio 703 .5.Business and Profarsiom Colic:Any city or county
S$ which armed.a Pemhit m construct.Blur,improve,demolish.or mpur any auuctum I
—Zi
poor it)its inuance,also uquiru me applicant forauch permit to lilt a signed auumcnt
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that he is licensed perlumt to be,provisions Of the Commit License Law(Chapter 9 Sq. Ft. Floor Area Valuation 0
$ (commencing with Section 7000)nr Division 3 of the Business and Professions Critic)or
mat he Is exempt therefrom and the baso for the alleged exemption.Any violation of
Suction 7031.5 by my applicmt for•permit subjects the applicat to a civil penalty Of ApN Number Occupancy pry,
not mom than five hundred dollars(M). P y `JPe
❑1,u owner of the pmpmy,m my employees with wagm u their mle comMnsatim. 35907005 . 00
will do the work,and the sroctum is not intended orottered for sale(sec.7044,Business
and Profemiom Code:The Communes Liarue Law dao nal apply ro an ownm of Required Inspections
Property ah.Wilds.,improvutheuon,andwho dassahwork himself.,dough his I
aanemploycea,provided thataah impmvemenu ane not intended aroRered formic.If, {
however ill how
or impdim or sprom proving that
the id one year of completion,me owner <
.]alder will have the burden of proving deet he did rot build or improve for porpase of \ \\\\V
tile.).
❑1,as owner of Ne property,am exclusively contacting with Ilttmed contractors to
came La the project(Sec.o an Business and property
who m Code:)The Camrerme. red
cease law dos not apply roan owner of property who Wilds ra Improvm Norton.and ✓\
who contracts for such porjects with a contacmKA Ilansed punuam m the Contecmh \V\
License law,
1 em exempt uncle,Sec. .B&P C for dela usson i
Ower Dau
WORKER'S COMPENSATION DECLARATION
1 hereby affirm under penalty of perjury am of dee following dalantiona:
have and will maintain aCerifieau of Consent to sel6imum for Wadura Compen- t
action,u provided for by Section 3700 of the labor Code,far the petfarmma of the ri
work for which this permit la issad.
❑1 have and will maintain Workers Compcmndon Intercom,as acquired by Section \I
31
'00 of the labor Code.for du per..ice of the wick fa which this permit if behead.
try
My Workers Crro�mmp-erepai Imiuu mous titrant and Policy number am:
Capper .) I�17)• Full l� Poli No.: J 44—2 00`
CERTIFICATE OFEKEMPTI cy ORKERS'
COMPENSATION INSUR)WCE
(Thr section need not be completed if the permit Is for one hundred dollars(S Ii
or leas.)
I certify that in the performance of the work for which this Permit Is Issued.l.rha11 not
employ any person in any mannerse as to become subject to the Warkcri C.mpensston
Laws of California.Dam
Applicant
NOTICE TO APPLICANT:If,after making this Certificate of Exemption.you should
become subject in me Worker's Compensation provisions of rW labor Colic,you most
., forthwith comply with such provisions or this Permit mill W deemed revoked.
70 CONSTRUCTION LENDING AGENCY
[-a Iherebytal.mat there is a construction lending agency or Ferformaac of
w dre work for which Its permit is issad(Sec.31 Civ.C.)
W Q Landers Nome
5 z lenders AM.
U 0 1 artily that I have mad this application mW mte mat the about information is
(A F correct.l i to comply with all city and county ordinances and sesta law$relating to
0 V Wilding construction.and hereby iumarire represenurivcr ofmis city to tour upon the
W abovcmentiamd property for imPemion purposes
wgy (WO)agree to dere,indemnify and keep harmkar de City of Cupertino against
fA liebililim.judgmcnu.cmu udexpcnsca sura Amey In any way eccmc against said city
U z ADPLREc,
D RSTANDSIAND W COMPLY WITH ALL NON-POINT Issued by: Date
\\
50 A
p �I/� Ll0 Re-roofs
Signal,e of Applican/Contrsctar Iau
HAZARDOUS MATERIALS DISCLOSURE Type of Roof
Will the applicant or futum building ocupul sore or handle huWous material
u dented by da Cupertino Municipal Cade.Chapter 9.12,and thO Health and Safety
oda,section zss3ze.)7 �H� All roofs shall be inspected prior to any roofing material being installed.
nYm
If a roof is installed without first obtainingan inspection,I agree to remove
Will the applicant or future building occupant taw equipment Per devices which P g
hayardous airconuminan u&fined h Bay Area Air Quality Management all new materials for inspection.
miOT
❑Yes Nu
Llh..W am ops materials requirements under ChaFterd.95.fthOGlifor,
nuyQdOc, mu 25505.25533and25534.1uMenuMmuifine building
liay hh�te ter that it is my res den Clary e notify scup g ppuychmus rot�t+o��rtullissuanco Ccnificauof0ccu Signature Applicant Date
ow crunuthorincdegcm `--^�� Date All roof coverings to be Class "B"or better
a 1