04030236CITY OF CUPERTINO
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86coN"rRlJk.I�A Q IURMATIQ�
BUILDING DIVISION PERMIT
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BUILDING ADDRESS:
D & D CONSTRUCTION
PERMIT NO.
04030236'
ER'S NAME:
PERMG ISSUE DATE
ONE:
SANITARY OL NO.
ARCHITECT/ENGINEER:
BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
0 0 l�
LICENSED CONTRACTOR'S DECLARATION
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lob Description - -
1 hereby affirm that l am licensed under provisions of Chapter 9 (commencing
with Section TORWDivision 3oftheBiomass tied Pro(euions Code, and my license is
Li icenlse Class erfec6 Li..0
REVISIO -CEILING '
MIT ISSUED/ORIG. 404030236
°ens Contractor
ARCHITECTS DECLARATION
1 understand my plans shall he used As public records
Licensed Profesional
OWNER -BUILDER DECLARATION
I heathy affirm that I am exempt from Ne Communities License Law for the
Following recon. (Section 7031.5, Business and Profession Code: Any city or county
which requires a Permit to construct, altar, improve. demollsh, or repair my structure
poor At its issuance. ales° requires the applicant for such permit o file a signed statement
that he is hemewd pursuant to the provisions of the Contractors License Law (Chapter 9
Sq. Ft. Floor Area
Valua'
(commencing with Section 7000) of Division 3 of the Business and ProfcuionS Code) or
that he a exempt therefrom and the bus for the alleged cumptlon. Any violation of
APN Number
Occupancye
Type
Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of
not mom than Bra,hundred dollars (M).
❑I,uowner of the propeny,smy employs with waguuthelrsole compenutlon,
35915048.00
Required Inspections
will do the work, and doe suucto. isnot intended to offered (orale (Sec. 7044, Business
And Professions Code: The Conuamars Liecom Law dos not apply m an owner of
propenywh t buildsor Improves dwason,and whodaeseuch work himselfor through his
own employees, provided that such Improvements are not inleaded oro@red forsaie. If,
however. the building or improvement is sold within ane year ofeomplcaon, the owncr-
builder will have the burden of proving that he did not build or improve for purpose of
as owner of the property, am exclusively contracting with licensed contractors to
\
And Professions Codeor :) The Contactors Lt.
the project (Sec. 7044, anon
a themracand
wriso La ofp rty who
not apply rota
lawU2.9
dth. pursuant
who contracts fo tach 'cis withacan r(a)Iisnxd pursuant to the Contractor's
who UI licensed
g�
License w (\
❑lam t tler Sew .B&PCT this n
C
i
Data
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WORKER'SSATIOhlD LAR ON
I hereby afrrunder penalty of perjury rote lowing decluadons:
m
1 have and will mainain a Certirns of Consent to self-hisme for Workes
As provided for by Section 3700 of the Labor Code, for the performance a( the
work for which this permit is issued.
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FI I have and will maintain Workers Compensation Insurance, as required by Section
3700 of the labor Code, for the performance of the work for which this permit is issued.
My Workers Compensation Insurance carrier and Policy number am:
Carver. Policy No.: _
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
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( subsection Deed nothccomplewd if the permit is foram, hundred dollar,(SIM)
all less)
I c,nify that in the performance of the work for which this permit is iuoed, 1 shall not
employ any person in any manner so As to become subject to the W°rkers'Compenatlon
Laws of California. Date
Applicant
NOTICE TO APPLICANT: IL after making this Certificate of Exemption, you should
become Subject to the Worker's Compensation provisions of the labor Code, you must
forthwith comply with such Provisions all this permit shall be deemed revoked.
CONSTRUCTION LENDING AGENCY
1 beauty M. that dem is a construction lending agcrayi far the pcafmmance of
the wart for which this permit is issued (Ss, 3097, Co. C.)
Lenders Name
Lender's Address
1 sonify that 1 have reed this application end sum that the about information is
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bonding I ages to comply with city and county and etata laws relating a
ntdines; of
building and herby euthon repsesenmirns of Nis city to soar upon dm
y
entionconstruction.
shave -mentioned property (in im purposes,
(We) agree m am, indemnify and hop hay against
nify ankneep the City of
in an
liabilitres,Judgme cosi endexpenses whist may in anyway setae against mid City
against
I n consequcnco the ranting of this 't.
APPLICANT R ANDS AN ILL COMPLY WITH ALL NON -POINT
Issued by: Date
S I RC LATI r p
I�
Re -roofs
- Type of Roof
Si arc fA m HAZARDOUS ATERIALSDISCLOSURE Daa
Will the applicant or future building occupantstore mhandlc hanamous mamoal
Afford by the Cupertino Municipal Caac, Chapter 9.13, and the Health tad Safetye.
35532(a)?
All roofs shall be inspected to any roofing material being installed.
[3ye,
Yes NoWill
prior
If a roof is installed without first obtaining an inspection, I agree to remove
the applicant orInto building occupant use equipment or devices which
havardous Dir contaminants u defiined by the Bay Area Air Quality Management
all new materials for inspection.
❑ YcsI
I.quiperic
have read haardnsmaaols aqui nts under Chapter 6.95 of the Califer.
Health&Sofro m25505.3553 u 534.1 unticrsumtl thalifthc building
not urreml M1 adna Na 't is m rc naiM1ility m notify the weupant
rust asp' its earaConirsmafGb pm
jgnatureofApplicant Date
All roof coverings to be Class "B" or better
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ncr ansa ascot