05050028 CITY OF CUPERTINO
BUILDING DIVISION PERMIT cOITILAC�ORaINCII2MATIQN i%.
.-.n hJ•� ., .J;^K�,iz seta e .'YA!',�, Fa?E
BUILDING ADDRESS: PERMIT NOO 5 0 50028
AM 10435 N TANTAU AV
qP OWNER'S NAME: PERMIT ISSUE DATE
HEWLETT PACKARD 005
PHONE: SANITARY NO. CONTROL NO.
ARCHITECT/ENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
�0M LICENSED CONTRACTOR'S DECLARATION Job Deicri tion '
1 hereby affirm that I am Lim mod under provisions of Chapter 9(commencing P
with Secdon 70M)of DlvWon Sof the Business And Professions Code,and my limns is
infull mrmmdeffen -?5'10t ( INSTALL PDU
f l a License.Claus0
m
G Dam cmcter � - CONTRACTOR: WOLF ELECTIC. (BL NO. #20440)
ARCHITECTS DECLARATION
I understand my plantashall W used As public record,
] U
Z O Lxcued Professional
OWNER-BUILDER DECLARATION
W FF I hereby.flim that 11. exempt from the Conlns Co License Law for IM
i O O following moan.Permit
u 703 1.5,Businos and w.de mli Cade:Any city Of moue
9 which requlw• ,alsoned.dis,ales.improv,deermitt,ore signed statement
pd.mits
censed e,alsumgr to oe applicant fo such penteisU"dtigredsuumenl - t.,.s,
thatM is meccgwith Semanuao)of Dislouof oar Comrsebh Limns law(CMper9 $q.FC.Floor Area VaIU$t$TBQQQ
(coa lbei he is
xe pth Section7")and of Division f r the
the Business edxe end Proon.Any
Cede)of
dot he 4 esempl dem(rom and de buts for de atkged exemption.Any violation of
Secdon 7031.5 by any applicant for a permit subjects the applicant in a civil pcuhy of APN Number Occupancy
am om dun hundred dollars(5500). ^ Type Ow
31606039 . 00
❑I,M ownerofthe property,wmy employees with wguuthelr role compew0on, ' l..` n n _
willeo llewmk,md meseoctum isnothurided or¢@red forNe(Sec.7044,1lushmas I' n u -
and Profesatoo C¢dc:The Camrscme,License Law does not apply m an owmr or Required'Uspec[IOn3r
property.1w Wild,mimprow dracon,md who dommch wodt himselfor through his
ownempleyme,provided that each Impmvemenuare notlnundW m¢Resed forests.If. /
bowewr,the building or improvement is mid within one year of compinkn,the owner.
builder will have On,burden of proving that M did not build or improve for purpose of C ?DDS
sale.).
❑Los ower of the(Sm.
.Business esand comrMins with:)Theed m rscm's a
cesen La the es not (Sec.]O nneofsed Pro(odau Code)The Canuacmr's nd
wtate low coca not apply m m ower ofpropertywho builds or improv Contort.and
who contracts for such proJeeu with a conusemr(a)licensed pursuant in the ConmcmYe
Lkenm law.
� am exempt under Sea ,B&PC fw this reamn
w Dam
WORKER'S COMPENSATION DECLARATION
I hemby affirm under peulty of perjury,one of the following declarations:
unio❑iltaw and will forbyneCion 37M of the Labor
Code,
eW9rhr'scempeo-
work f r provided for by genion 3700 e(the labor Code,for de Performance of the
work for which this Permit Is issued.
❑I have and will maintain Worker,Compensation Insurance,u required by Section
3700 of the labor Cade,for me performance office work fwwhich this permit is Wood.
My Worker' Cempenudon lnwran¢tinier and Polity nula": '
artier. Mr./ti Polity No.:
PILON FROM WORKERS'
COMP ATION55
INSURANCE
(Thus swim deed ret becwnpleed Irthe perch 1sf¢rone hundred 011m;(SIM)
or Ices)
I unify that in the perfomanee of the work for which this permit is Issued.I&hall not
employ anypermn in my mmerm As to become subject to the Worker&'Compensation
Laws of California Dam
Applicant
NOTICE TO APPLICANT.If.after making this Ccniflaw of Exemption,you should
become subject m the Worker's Compensation provisions of the labor Code,you mum
O forthwith comply with such provisions w this permit shall v deemed revoked.
zy CONSTRUCTION LENDING AGENCY
(-� Iherehy AM.that then is a construction lending agency for the performance of
gy' the work for which this permit is issued(Sm.3097,Cih,C.)
W Q Lender's Name
.a7. Z L.Mes Addeo '
U Q 1 o rdfy Out I have read this application and sum that oe show information H '
Vy r'. comm.l agree in comply with all city and county ordmancea and sue laws relating m
O rV^ building commetion,and hereby amhorlee repmacnmiw of mix city m enter upon the
W show-mentioned property for inspect¢.purpmes
fi (We)agree in taw,indemnify and keep harmless the City of Cupertino agaiw
C.W liabilides,Judgmenu,cotsand,.leva which may In anyway sane againstwid Clay '
)7 iomucgmo¢ofthe,randngofthispemiL
rte• APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT Issued by: Date
SOURC EGULATIONS.
"O Re-roofs
ignatmcof Applicart Corrector Dae
HAZARDOUS MATERIALS DISCLOSURE Type of Roof
Will the applicant or future building accupen amre whandle huardou material
flood by the Cupenlno Municipal Cade,Chapter 9.13,and the Health and Safety
C.Secdon M533(a)7 All roofs shall be inspected prior to any roofing material being installed.
Oyu ❑No
Will the applicant or fumm building occupant One equipment or&,I=which If a roof is installed without first obtaining an inspection,I agree to remove
emit hanrdeus air comaminanu As defined by de Bay Area Air Quality Management all new materials for inspection.
DiWica7
❑Yes ❑No
I have mad the husrdousmaerialsroquimmenu underompu06.95 of L e Califon
nia Health&Safety Code,Sections 35505.35533 am135534.1 understand thuiftee building
dors not currently haw a levant.Our It Is my numendbllhy to notify the cmupant of the
mquiremcn hichmust6cmelpdorm' uareo Cwtifteae fOccu Signature of Applicant Date
nrmma ,<da tent Dae All roof coverings to be Class"B"or better