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CITY OF CUPERTINO
BUILDING DIVISION PERMIT
xxCO1VT1tAC'OR INFOItMATIg1V:
BUILDING ADDRESS:
PERMIT NO.
4030151
NER'S NAME:
PERMITLSl1EDATE
12
NE:
SANITARY OL NO.
ARCHITECf/ENGINEER:
BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
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LICENSED CONTRACTOR'S DECLARATION
Job Description
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1 hereby affirm Net I am licensed under provisions of Chapter 9 (commencing
with SeeUan 70aa of Division 3 of as, Business, and Profesdou Code, shat my license is
LimueCl and`E" II �f
EXPANSION OF UNDERGR'D GARAGE
Dam a -i
r PARKING LOT CONST/RETAIN WALL
cCommusterDECLN
1 undenund my plans shall W used As public mends
Licensed Pmfeuianaf
OW111R.-BUILDER DECLARATION
1 hereby affirm that I am exempt from the Comatelors License law for the
-
following mason. (Swam M31,5, Business and Professiuna Cade: My city or county
which requires a permit in emmruct. alcor, Wprow, demallsh, ser repair my Samoan
prior ae its issuance, also requires oxa applicant forsuch permit to file a signed so mmenl
Cantrector's taker Law (Chapter 9
Sq. Ft. Floor Area
Valuation
Met he is limmed pursuant to the pmvisiom of the
(commencing with Section 7000) of Division 3 of the Business and Profeuiom Code) or
out be Is exempt timrtfrom and the basis for the alleged exemption. My violsdm of
APN Number
Occupancy Type
Secom 7031.5 by any applicant for a permit subjects the Applicant M a Civil penally of
not mom than five hundred dollsra ($50)).
❑ I,uowterofaepmpeny,ormyempbyeeswiaweguuU trmkeompenutlan.
20084.00 Required Inspections
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will do the work and lheswnue Is otimmoded oraaered formic (SAO. 704/, Business
and Profession Code: The Contractors Lim. Law exam at apply to an punter of
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property who builds or imposes thereon, sed who does such work himself ar auough his
cove employees, Provided that such improsemenu ase notimmmdd or offered for ask If.
however, the building or imp roamenI is mid within cm Sear dmmpletice. the xawnor-
builder wIB hese the wow of Moving oat he did not Wild or improve fm purpose of
sale.).
❑ h as owner of the property. am exclusively contracting with lienneed mntractun 10
convect the project (See. 7044. Business and professions Code:) The Cmtnctorl Li-
cense law dors shat apply to an owner of pmpwy who Wilds or improves m soon. and
who convects for such projects with a cuntrsetor(0 licensed pummat to as, Comontars
License Law.
"
❑ I Am exempt under Sec. ,B&PC for this tenon
Dam
WORKER'S COMPENSATION DECLARATION
1 hereby alEws under penalty of perjury ane of the following deciarallons:
❑ I have and will maintain aCer ifteam of Consanuo selblnaum far Worker's Compen.
Milan, m provided for by Section 3700 of the labor Code. for the performmm of the
work for which this permit Is Issued.
❑ 1 have and will maintain Workers Compensation Insurshme, As required by Section
3700 of the Labor Code, far the performance of the work for which this permR Is Issued.
My Workers Compensation Imsenna artier and Po11ry number aro:
Cartier. sLSA L^S%lam %fG)F WORKERS'
'
CERTIFICATED EXTI I NFROM
EXEMPTION
COMPENSATION INSURANCE
'
(This section need not W eemplemd if M, Vomit is Emote hundred dollan(SI W)
or Mu)
1 cenify that in the poonexam of the work for which this Permit is issued. l Mall not
employ any person in my maanerm as to become subject 10 the Warton' Compensadm
Law of Cnifxamia. Dam
Applicant
NOTICE TO APPLICANT: If. after making this Carant a of Exemption, you Mould
become subject to 00 Worker's Compensation previsions of the labor Code, you must
forthwith Comply with such provision or this parmil shall W dcamd mvukd.
CONSm ON LENDING AGENCY
Is a c lending gonry for the performance of
oatmereba
1Mrwhich
Wood
the wash far which cels pemtlt ls immd (Sec. 7097, Civ. C.)
this
Leaches Name
Lcndeh Mdrcm
1 I ttnify that 1 haw read this application and sum that the show Information ls
Corrtm, I agree to comply with all city and county ordinances and sum Ion mining to
Wilding construction, and hereby moodw representatives of this city to enter uPnn the
above-mentioned property for inspection purposes.
(We) agree to save, Indemnify and keep les mlem the City of Cupertino against
j liabilities,judgment, costs ad expenses which may In my way seeress, against said City
In cmtsequeac of to Starling of this permit.
' APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON -POINT
Issued by: Date
SOUR
building oucupmisart or handle havardous material
As de0ned by the Cupertino Municipal Code, Chapter 9. 12, and the Healm and Safety
Code. Secom25531(a)7 J
All roofs shall be inspected prior to any roofing material being installed.
❑Yes
If 8 toot i5 installed without first Obtaining an inspection, I agree to remove
Will the applicant or fumes WildhS onvpam useequipment or dcvitd which
emit hmardom air comeminan u dcfrmd by the Bay Arm Air QuMly Managcmem
all new materials for inspection.
District?
❑ Yes
Ibmctmdoe Mnrowsmamrialsmqu menu under Cha ter6.95 oroe Califor.
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