03090142 CI TY OF CUPERTINO ��s,� " �y '(�0,j� '' mn -
BUILDING DIVISION PERMIT �'lil" - IN ^
:�s >, y.o .Y s, -
BmILDINGADDREss: WM H FRY CONSTRUCTION COMP ITN(b3-090142
881 TUT-A CT
OWNER'S NAME: PERMIT ISSUE DATE
MERALA MARK
E; SANITARY NO. CONTROL NO.
(408) 996-8173
ARCHITECDENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
+�o O LICENSED CONTRACTOR'S DECLARATION
I hereby affirm that I am Resound under previsions of Chapter 9(commencing Job Description
with Smile.7010)of Division 3 arrive Business and Professions Coce,end my license is
in mum
force andeffea SEISMIC UPGRADE
S�? License Class Lb,g
tor
nF�
at Cedar pis
"J ARCHITECTS DECLARATION
�i I understand my plena shall he used u public mcaNs
OyyU
3Oy
Licensed PNICb51a11B1
Q <l OWNER-BUILDER DECLARATION
d 1 heresy affirm on 1 1. exempts an Rte ContoTessio Co :License Lew for the /
0 o following reason.aped t 7 mean Business and approve,
de nm Code:Any city at county CZY.
$i which requires a pmmit re cnwwm,epee i t forsu demolish. fl srepair anygned structure
Hopdormits ceensed e.pslso uantto requires pre inion of forsuch cense Law(Cha statement
that he is licensed pursuant lathe of Division 3 NC Conusines iLieemselaw(Chnpmr9 Sq.F[. Floor Area Va n[IOn
Ho
(commencing with Section]000)nf DivisionJnf the Business and Prafmsiaas Cade)or y
Nal he u exempt d amfrom and Ne basis for Ne alleged exemption.Any violation of Ia
Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of
not ream Nan Eva hundred dollars($500). 3.r]�I®IfiIibe10 O _ �Cl)panCy Type
❑I,as owner of the property,or my employees with wages as their sale compensation, �.JJ
will do the warp and the struaum is not Intended or offered for 1010(Sm.7044,Business Required Inspections
and Professions Code:The Cormaemr's Liwm r law done not apply b an owner of q p
property who builds or improves thereon.and who does s uch work himsel f ar through his
own employees,provided than such improvements am net Intended oroffered formic.If.
however,the building ar Improvement issold within one year of completion,the owner.
builder will have the burden of proving Nat he did not build or improve for purpose of
sale.).
❑1,as owner of the property,am exclusively compacting with licensed contractors to
construct the project(Sec.7044,Business and Professions Code)The Commences U.
cove Law does not apply to an owner of property who builds or improves Demon.and '<
who contracts for such projects wit a conuutor(s)licensed pursuant to the Contractor's
License Law.
❑1 am exempt under Sec. .B&P C for this recon
wncr Data
WORKER'S COMPENSATION DECLARATION
I hereby of ion under penalty of Perjury,one of the fallowing declarations:
have and will maintain a CertRimm of Consent to self-Insure for WorkersCompOn-
ation,as provided for by Section 3]00 of the labor Code,for Na performanw of the
work for which this permit is issued.
❑1 have and will maintain Workers Compensation Insurance,ss required by Section
3700 of the Labor Code,for the peRmmanec of the work for which this permit is lowed.
My Workers Compensation Insurance carrier and Policy number am:
Carrier: Policy No,:
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(Thlasenlon wed noteccomplebd if the permit is forane hundmddallan;($100)
or lcbb)
I certify that in to.performance of the work far which this Permit is issued.I shall not
employ any person in any manner an as in become subject to the Worken'Compensnlon
Laws of California.Data
APPliumt
NOTICE TO APPLICANT:IL after making this CcniRcab of astatine.,you should
become subject an the Workers Com acodon provisions of to Labor Codc,you must
Q O forthwith comply with such provisions or this Permit shall be deemed revoked.
„Z„^' CONSTRUCTION LENDING AGENCY
I hereby affirm Nm them is a Construction lending agency for the performanm of
Ci> the work for which this permit Is issued(See 3097,Civ.C.)
WM Q Lenders Name
Q z Lenders Address
C)Q I certify that I have mad this application and sub Nat the above information is
l[v F COMM 1 agree to comply with all city and county ordimanues and sum laws relating to
Q V building construction.and hereby auNarim representatives of this city to enter upon the
4i] ahavcmentiuned properly for ins,main purposes.
gy (We)agree to neve,indemnify and hep harmless the City of Cupertino against
C4 li
abilitiu,judgments,costs and expenses which may In any way acerae against said City
[„)Z in consequence of the granting of this permit.
^" APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT Issued by: Date
SOURCE REGULATIONS.
Re-roofs
Signature of ApplicaDare
HAZARDOUS
US MATERIALS DISCLOSURE Type of Roof
Will the applicant or future building occupant erre or handle hamNaus material
as defined by the Cupertino Municipal Code,Chapter 9.12.and the Health and Safety
Cade,Section 25532(a)? All roofs shall be inspected prior to any roofing material being installed.
C]YC' ❑Na
Will the applicant ar fmmc building occupant use equipment or devices which If a roof is installed without first obtaining an inspection,I agree to remove
s haamdn.c air commminants as dented by Ne Bay Arca Air Quality Mamt cmcnt all new materials for inspection.
]
Q Ycs ❑No
I have mad the hxvardous materials requirements under Chapter 695 of the Califor.
nia Health&SafegCode,S dom25505,25533and8534.1understand Nasifthe building
does oat cunantiy have a resent,that is is my responsibility to madly the oecupan,or the
requirements which must be mel prior to issuance of a CcrtiOcam of Occupancy. Signature Of Applicant Date
Owner or authorixed agent Date All roof coverings to be Class"B"or better