00090129-r IIU11.mNG DIVISION v PERMIT I CONTRACTOR INFORMATION:
BUILDING ADDRESS:
_a
OWNER'S NAM[ -.0300 TOR
PHONE: MERRILL L
ARCHIT'EC'T/Hi UNIFIER
LICHNSP.DCON'IRACIOH' S DECLARN'ION
1 Imrchy Ell i'nt That I ant h,enoal under...... eium of Chmtc' 9 tcn'un'eneing
wllh Section 71X(1 of Division 3 of the Nusincaa and Promesiom Code. and any license
I'm full force and elle
Limn acyl .+ e" C S' M
orale uf/__, tl�D_I cnnnaen
ARC it I'Ibe a S UP.CLA e N
I undcrstund nmY Plena ah'JI he axed as pnnllc rcenrcL.
Licensed Professional
OWNER -BUILDER DECLARATION
I hereby utlina tha' I con cacao, amu the Contractors Liceme Law Ibr the
following reason. (Seeaion 7031.5. Ilea rad Panes cox Cndc: Any ei,y o only
Pr
which rap'iresa perndl re utresthe alcor, improsu demolish, Orr repair any statement prior rat ins issnencc.alsoatto be the applicantfor eachpenniuolinoa Jgncd atmcmcm
(ex be it Iimnwit punuanl to the pmvrstoir of the C e Beside, Liccnsc Irw (ChapterCod )
(commencing con Section HXM1) I tDivision 3 at he jecod s and i i. Any i Coda)
or'hel he is 31 5 b Imay ap li and the basis for lhu alleged fplilz fiI a, Any violation
of I,,, on e Ira 5 by xray applidnn fur a icor Ell xuhjcc'e the upplicum m a c'v'I pomhy
of Ern more Non five hundmJ Jnllacs (851N)).
01, as owner of the profeny, or my ctnpluyces with wages as their woe compemation.
will no the work, and the structure is not intended or offered for sale (Sec. ]loaf•
b.,oac,a and Pntfmsions Code 'Han Contractor's Licensc Law does not apply to an
,otneit co,,, y W1 bounds or unquote, Ihcrion, and who cine, inch work am,elf
ur Iltmugh his own mnpinym. mo,alod Ihot tech Intprovcnu7us arc nm intended or
Ordered lar sale. IL however. the heilding or intpnncmem is sold within one year of
untpleion, the amnerrbullder will have the burden of proving that he did non build or
nmpruve for parfow at tale.).
01, as owner of the ..... pony, inn exeluaivcly suarmling, wldl lieemed ennm¢vtrs to
Ltmtme' the project (See 7044, business and Profetsiom Calc:) The Commctor's
icense law Jees not apply la an owner of property who build, or improves thereon,
and who contracts for such projects with Or commetorlsl licensed pursuant to the
Cmnrictors Licemnc law.
CIEInt usempl antler See. . it Nr P C On, thla'coon
Owner Dane
W'ORKER'S COMITNSATION DECLARATION
I Imreby affl under pemJly of perjury Enc of the following dcclarmiom:
❑ I have and will initiation n Certificam of C'nnnnl to self -insure lin Worker's
Cmngemelion, as pmeided for by Section 3710 of the labor Cada for the
performance tilde work (m which this permit is issued.
Ott hate and will IannaiLio Wurket's Con trenealoo Insurance, as required by Section
3700 of the Labor Coda, lit, the pd
eor of the wads fur which 'hi, pc nil it
issued. My W'or •r, Cnon,..a'inn Insurance ar
nce crier d pub, number are
son
C:nsa:�p,vv .Policy wNo.:.L.-LA CIERI IF A7.t—olt1
ION (1P EXEMPI'R1N FROM WORKERS
COMPIiNSATION INSURANCE -
('this section need not be completed if flan perndl in for Ene hundred dollars
IS (Aft it, leis.)
I cenlfy that in the performance of the work for which this permit is issued. 1
shall nal employ any pcmnn in ;toy'manncr su as'u hcconic suhjod ,, he Workers'
Cmnpemanmt lawn of Cold mltia. Dore
Appfeam
NOTICE TO APPLICANT: IL after necking this Cenifcam of Excmplion, you should
hecome subject to the Worker's Conmpenwtion provikions o(the Lahur Cade. must
ust
Itmhwllhcon'ply wIli such provisions or this Formol shall be&Eamd revokod,
CONSTRUCTION LENDING AGENCY
I hereby affirm that them is a mnsuuction lending agency for the perfomnnce
of the work for which this permit is issued (See. 3097. Co. C.)
Lender's Name
1<adcr's Address
I cert i tha' I hove mad this applicmion ,.,it su'c tha'he ohne information is
correct. I agree to comply with all city and county endurances and stoic laws relating
rat huildimg conswction, and hcrthy authorise rtprc>ennttives of Nis ciry at enter, uptnt
the ubno-menliuncd properly for inspection purpltm.
(Wc) agE c,, onto. Inden"d I y;nal kip I El,,, be City n(Cupcniao against
Iianilhica, and uper,c, whmh may Ia any way accrue against .said
C.— in. nnwmence of'be emnline of his cermil.
HAZARDOUS MATERIAI S DISCLOSURE
Will the applieanl or future vending uccepont dere or handle hv:W:Ius material
m defined by the Cupertino Municipal Chapter 9.12, and the Health and Safety
Code. Section ]55311.)7
12 Yes
Will the applicant or mune bonding occupant use syuipmcar or donees which
coif hararJoas our contaminamt as defined by the bay Amt Air Quality Management
District?
OYes
I have need One hamrdnua mammals m1laireacats under Chaotic' 6,95 n! the
Culdomia Health k Sol'cty Gyle. Sections' -5505.25533 and 25534. 1 understand Ihm
if the building dues not curmmly hie a anon,. that if is my respumibilify for doody the
oecapin of the rcquimments which must he met prior to issuance of Or Cenifcaa of
DEMO
YI19311Eifiss@
No.
❑I.D(It ELECT PLUMB MECH
Job Description
Inspections
NO ASSIGNED INSPECTIONS
Issued by: ar<__ Date F' --ems Ut)
Re -roofs
Type of Roof
All roofs shall be inspected prior to any rooting material being installed.
If a roof is installed without first obtaining an inspection, I agree to remove
all new materials for inspection. Applicant understands and will comply with
all non -point source regulations.
Signature of Applicant Date
All root' coverings to be Class "B" or better
46
CITY OF CUPERTINO
BUILDING PERMIT APPLICATION FORM
Building Address:
Owner's Name:
Phone No:
_y s
Contractor:
0
License No:
Contact:
-4'
Phone No:
b ,
Architect/Engineer
C
License No:
Applicant/Contractor:
Energy Add Multi
Building Permit Info: (circle one)
Idg Elect Plumb Mech
escription:
Residential: Commercial: t ."T
Sq. Ft. Floor Area: el
S/Sq. Ft.:
APN,# (Must provide):
Valuation ibjoo<=>
Type of Construction:
Occupancy Group:
Qty. if Fee ID
A licable
Fee Descripflon
Fee Group
BTEMPPERM
Temporary Bldg Permit
IBUILDING
BCONSTAX
Construction Tax
fBUILDING
BENERGY
Energy.
BUILDING
BENERGYADD
Energy Add Multi
BUILDING
BOVERTIME
Inspection Overtime
BUILDING
BPERMFEE
Bldg Permit Fees
BUILDING
BMITIGAT
lHousing Mitigation Fee
BUILDING
BPLANCHK
IPlah Check Fee
BUILDING
BPLANCKADD .
IPlan Check Add Multi
BUILDING
BPLANCKREP
IPlan Check Repeat Fee
BUILDING
BREINSPECT
lReInspection Fee
BUILDING
BSCBLVD
IScb Specific Plan
BUILDING
BSEISMICOM
Seismic Commercial'
BUILDING
BSEISMICRE
Seismic Fee Res
BUILDING .
BSPECIAL
Special ins ection
BUILDING
BSWIM
Swimming Pool
BUILDING
ZADDCHG
Address Chane
BUILDING