04030160 CITY OF CUPERTINO
BUILDING DIVISION PERMIT CONTRA. 'OX2,IrTk`dRIVIr�TON .
1
BUILDING ADDRESS: PERMIT N0.
]Nj
ASSOCIATED CONTRACTORS COR 04030160
PERMIT L5E00 DATE
OWNER'S NAME:
SANITARY OL NO.
ARCHITECTMNGINEER: BUILDING PERMIT INFO
BLDG ELECT
PLUMB MECH
0 0 0
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Zp LICENSED CONTRACTOR'S DECLARATION - Job DeSCrI VOA
I bercby turns.that 1 am liconsed under provisions of Chapter 9(commencing P
^Z with Section 70(IIBaf Division 3 of NC Business and Professions Code,and my license is
< 51
m ren roma and erreck
gg oean:cclass Limaamtor TI--NEW WALLS
tg ARCHITECTS DECLARATION w '
5tgdd 1 undcnund my plain shall be useal m public rtcorN
y
G1n Licensed Professional
S OWNER-BUILDER DECLARATION
p 1 hcrchy affirm then I am exempt from the Contractor's License Law for the
Eno following trmon.(Section 7131.5,Business end Profmsions Coale:Any city or county
off which ,of.a permit to convect,alcor.improve,demolish,or repair any sweture
fY^ prior to its issuance,esu rrquircs the applicant for such Permit to Ne a signed ctanment
that he is licensed pursuant to the provisions of the Common's License Law(Chapter 9 Sq.Ft.Floor Area Valu tion
y $ (commencing with Section 70DO)of Division 3 of the Business and Professions Code)or
.. Net he Is exempt themfrom and the basis for the alleged exemption.Any violadan of
Section 7031.5 by any applicant for a permit subjece.the applicant to s civil penalty of 3 gk�Ill0j&p qr0 0 Occupancy Type
not mon Nan five hundred dollen($500). O"J
❑I,mowmr of Ne pmpenY•or my emPloyem with Magmas their sele compensation,
will do the work,and the$Mone is nut intendant or offend for sale(Sec.7614,Business Required Inspections
and Professions Code:The Contravenes License Law s no
doct apply n e an owner of q P
properly who builds or improves thereon,end who dere such work himself or through his
awn employees,provided thal$uch improvements am not fiwndent oroOercE formic.if,
however,the building or improvement is said within one year of mmplca0n,the owner.
builder will have the burden of Proving Nat be did not Wild or improve for purpose of
sale.).
�-1,as owner of the propeny,am ascimively contracting with licensed contractors no
comwct she project(Sec.7W,Business and Professions Code:)The Comactor's U.
cease Law does not apply to an owner of property who Wilds or improves Nemen,and
who contracts for such projects with a contractors)Hamed pursuant to the Connector's
License Law.
[D Iamexempturalm Secc.. � ,B@PCfm Nisnason
Own v V Data p
737MWORKER'S COMPENSATION DECLARAWGAIs
1 betray affiM under pemlty of perjury am of Jas foPa��-1s declvetime:
has and will maintain aCcnificale of Consent to self-insure for Woraare COmPen-
n,u provided for by Section 37M of the Labor Code.for the performance of than
for which this permit is imued.
lave and will maintain Worker's Compvnation Insurance,m requite by Section
of the Labor Code,for Ne performance of Ne work for which Nis permit Is imued.
Worker's Cnmensadon Insurance tamer and Policy number am:
er: Policy No.:
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(this section wed not be complete ifthe permit is faronchundmddollars($1011) '
err less.)
1 certify Nat in the performance of to work for which this permit is issmd,I shall not
employ any person in any mmwrm as to become subject to the Worker!Compca tkat .
Laws of California.Date
Applicant ,.,
NOTICE TO APPLICANT`.IL after making this Cenificam of Exemption,you should
become subject to Ne Worker's Compensation previsions of the Labor Code.you must
Z forthwith comply with such provisions or this permit shall be decmcd nwnkad.
zO CONSTRUCTION LENDING AGENCY
[-i Ihereby of ons thnthers is a communion lending agency for the performance of
Oar.> the work(tar which this permit is issued(Sec.3097,Civ.C.)
QLerulms Name
a z Lender's Address
U Q 1 certify that 1 have mad this application and sun that Ne above information is
Vr F came,I agra to comply with all city and county ordinmas and sum laws miming in
DU Wilding comtroction,and hereby amhome rcprvwnudwe of this city to cnmr upon the
D.1 above-mentioned property for inspection purposes ���---ssa ♦♦♦
(We)agree m rove,indemnify and tech may
In my
the City of Cupertino id City
irk liabiliti(We)gre1.cas,indexpenses nifyand auto meylnanyweytywe=r upertino ag City [.✓..r/s /
L)Z in consequence of the granting of this permit.
^� APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT Issued by: Date
$0 RCE GULATIO
3 d Re-roofs
iincome o pplicant/Conuacmr
HAZARDOUS MATERIALS DISCLOSURE Type of Roof
Will the app1mam or future Wilding Occupant store or handle havardous material
m defined by the Cupertino Municipal Code.Chapter 9.12.and tim Health and Safety
ode,Section 25532(a)7 All roofs shall be inspected prior to any roofing material being installed.
❑Ym V.
11 Will the applicant or fume Willing occupant use equipment or devices which If a roof is installed without first obtaining an inspection,I agree to remove
mit hm amus air contaminates a defined by the Bay Area Air Quality Management all new materials for inspection.
District? W"�
❑Ycs
I have mad the bmaNnus materials mquinawas under Chapter 6.95 of the Califor-
ria Health&SafetyCodc.Sections 25505,25533 and 25534.1 u ulaward that!film building
docs not currently haw a tenant,that it is my responsibility to noul'y the occupant of Ne
mqulerwas which must ave met prior to too na.facamficamnfoce pancy. Signature of Applicant Date
venae or authormd agent arab All roof coverings to be Class "B"or better