07010053 CITY OF CUPERTINO a -i. 6 :+?n• -
BUILDING DIVISION PERMITCONRAGTQINFORMATION t
BUILDING ADDRESS: PERMITNO.
'R'S NAME: Awe
,EI MA 01/24/2007
PHONE: - SANITARY NO. CONTROL NO,
ARCHT CT7ENGINEER: BUILDING PERMU INFO
BLOC ELECT PLUMB MECH
0 0 0 0
+oa LICENSED CONTRACTOR'S DECLARATION - Job Description
w❑ 1 hereby affirm that provisions
at 1 Me Removed under of Chapter 9(commencing
U.
with S¢tion 7IXIU)OfDivision]afJm Busirry and Professium Code.and mylicenscu
H nd (fcet REVISION: GLUE LAM AT DINING ROOM LOCAL
in full force ae
jgz
Liken m Ire= Lie. ORIGINAL PERMIT: 06040030
Contractor
ARCH CTS DECLARATION
ea •1 understand my plans shall W used as puh&records
dr
k o in Licensed Professional
S OWNER-BUILDER DECLARATION
I I hereby mTsnn Nm 1 am exempt from tW Conmctor's License Law for the
Q o following mason.(Section 7031.5.Business and Professions Calc:Any city or county
e fL which require a permit m emcommet.ober,improve,demolish,ear repair any structure
prior mita issuance.alw rcquircs Joe applicant for such permit to rile a signed sutemenr
-�< that he is licensed pursuant to the provisions of Joe Contractor's License law(Chapter 9 Sq.Ft. Floor Area (• Valuation
yH$ (commencing with Section 7[W)of Division 3 of NC Business and Profeseinm Cnd $
c)or 77802
t�- that he u exempt therefrom and the basis for the alleged exemption.Any violation of
Section 7031.5 by any applicant for a permit subjects the applicmt to a civil penalty of ss pNNumber Occupancy Type
ler more than five handled dollars(SSW). 3 622 7 03 3 .V V
0 1,as owner of the Property,Or my employees with Per u their sole compensation,
will do to work.and Ne structure is not intended or offered for side(Sec.7(k4,Business ns Required Inspections
and Professors Cade:The ConuacmrS Licerme Law don set apply m an Owner of q P
pmpmty who Wilds or improves theleon,and whodamauch workhimsrdfor through his
own employcn,provided that such IMPROWmenu are not intended or offered for sale.IL
however,the building or improvement is sold within one yew of completion,the owner.
Wilder will have the Woden of proving Our he did not Wild or improve for purpmc of .
sal/t.).
Q m 1.as ownm of the property,am exclusively contracting with licensed rnnuaemrs m
construct cr d e project(Sec.7064,Business and Profee ons Code:)The Contractor's Li-
come law does not apply an an owner of pmpeny who Wilds or improves thereon,and
who commun for such project{with a cmdracte,4)licensed pURaanl to NC Cortisone,
1.#CnY ldw,
H lam eaemptu er 5e -.Bk{{PCfor this retain
Ilk` -
MF WORKER'S COMPENSATION DEC LAMTION -
1 hereby affirm under facility of perjury One Of the following declamriom:
O l have and will maintain a Cenifleam of Consent to self-insure for WortrrhCompcn-
smon,as provided far by Seesion 3700 of the Labor Code.ler the performance of the -
work lar which this permit is issued.
0 1 have and will maintain Worker's Competuauon Insurance,as metal by Section
37W of the Labor Code,for the performance of the work for which this permit is issued '
My Worker's Compensation Insurance carrier and Policy number art:
Carni Policy Na: _
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
Cnissection need not W completed if thc permit is fmone hundred dollars(SIM)
0'less.)
1 rof,,t1m in the performance of the work for which this permit Is mood.1 shall not
employ any person in any m. trio az)o come soh sea the Workers Compensation
Laws of California.D ��
NCMCSl
NOTICE TOAPPLICANT:If.after making this Certificate of of Laser Code.
you should
become Subject the worker's Compensation Or is Permit
o ithe IaWr Code.you retic
.JO forthwith comply with acs provisions Or Nu permit sloth Wdremed revoked.
'z h CONS RUCTION LENDING AGENCY
1--r 1 hereby a(lim Wt thele is a construction lending agency(or the Performance of
!Yi the work fur which this permit is issued(Sec.3097,Civ,C.)
W� Lender's Name
z L<^deh Address
O Q 1 certify that 1 have read this application and sum that the above information is
" f-' comet I agree to comply with all city and county ordinances and sum laws relating to
OU building construction,and hereby authorim reprnenunwes^/this city to cnmr upon lM
wah^vc-mm "tpc
nu ^cd P. y for inacuon purposes.
f^ (We)agree to save,indemnify and trop harmless doe City of Cupertino against
(Z) liabilities,judgments.costa and expenses which may in any way acemc against said City
U z APPeof the granting of r
LICANTSUNDERANDS AND WILL COMPLY WITH ALL NON-POINT Issued by: Dale
SOURCE REGULATIONS. /Ea,H Zg � -
Q 7 Re-roofs
Signature Of ApplicaHAZA DO Dam
HAZARDOUS MATE RTALSDISCLOSURE Type of Roof
Willy t applicant Cu,on or m,fumrc Wildingattupanlsmrc Or handle Health and
JIM cd by the Cupenim Municipal Code,Chapter 9.12.and the Health and Saler$
R.soyu 2ssu(a)7 �Na All roofs shall be inspected prior to any roofing material being installed. _-
Will the applicant or future holding Occupant use equipment or device which If a roof is installed without first obtaining an inspection,I agree to remove
emit hazardo.air coourrom e,as obef ed by the Bay Area Air Quality Managcmcnr all new materials for inspection.
DrfgLrict7
❑Yes �N0
T have read the haaarthvrs matenab requirements under Chapwrb.95 ofthe Califon
MA Health h SafetyCOde,Sections 25505,M533 and 25534.1 undeuund that ifthc Wilding
z does not cunenrly have a Le ant that it u my lespu OROiry m notify Joe Occupant of um
,cquucmenu wie riot m issmn¢of a Cenifeareof Occupancy.
Signature of Applicant Date
"N
Owner or authoriv<J agent All roof coverings to be Class"B" or better
Da¢'