04090231 CITY OF CUPERTINO --
BUILDING DIVISION PERMIT' - Cfy 'TItA, OR TLA OIAlLT,I �� i
BUILDING ADDRESS: COAST ,SIGN PERMIT NO,4090231
NER'S NAME: - PERMIT ISSUE DATE '
LOUR
PHONE: SANITARY NO. CONTROL NO.
ARCHITECT/ENGINEER: - BUILDING PERMIT INFO- -
BLDG ELECT PLUMB MUCH
0 0 0 0
LICENSED CONTRACTOR'S DECLARATION - -- ---— ----- -
Iion7 ).f NetIamRumored fthoBuundoprovisions nr.Chapsor Quix, 9(commcncing Job Description
with Sidon9de effect,
is
tita Husinessand Profeninm Code,entl mylicense is
n fan force end crcect.
z 5 Date Class C" Contractor
fO5, .1 SIGN
`h,p Date ]y req- Cun DECL I
❑W ARC adl to we DECLARA ON
1 understand my plans shell W wed an public memde
Licensed Professional
g OWNER-BUILDER DECLARATION
iI I hereby affirm Thal I am exempt from the Commctor's License Lew for the
F.D O following reason.(Section 7031.5,Business and Professions Code:Any city or county
$ 'which requires a permit to convect,altar.improve,demolish,or repair any swctum
pdm m its issuance,elm requires tW visions m far such permit la file se Law
solemend
that he islieenmJPursuenunthcpmvisionsnlNCCanwdor'sUccnm aw(Chepmr9 Sq.Ft. Floor Area Valu tion
at (commencing with Section 7000)of Division 3 ofthe Business and Professions Codc)or
�.•
that he In exempt therefrom and the basis far the alleged exemption.Any violation of ',.,.5, araC
Section 7031.5 by any applicant for a permit subjects the applicant m a civil penalty of 3 II�RIg7i�10r97e10 0 DQQn
not mom Nan Ove hundred dollen(1500). Occupancy TYpe
❑1,as owner ofthe prepeny,m my employees with wages an theirmle compensation,
will do thework,and theatmcwte is not intendrA in offered formle(See.70414,Business
and Professions Code:The Camodctor's License Law don not apply in an owner of Required Inspections
property who builds or improves thereon,and who duevuch week himml f ar through his
own employees,provided that such impmveme m;are not intended confined for sale.If,
however,the building or improvement is mid within one year of completion,the owner.
builder will have the burden of proving that he did not Wild or improve for purpose of
me.).
❑1.es ower of the property,am exclnively contracting with licensed contractors in
consuuet the project(Sec.7014,Business and P TUU ns Code:)The Contractors Lt. _
cease Taw dote not apply to an owner of property who Wilds or improves dmmon,and,
who contracts for such pmjems with s contnemr(p licensed pursuant to du Contractors
Lt....Law.
❑lamexemplunder See. ,B&PCforthismnon
neo Dau
WORKER'S COMPENSATION DECLARATION
I hereby affirm under penalty of perjury oat of the fallowing declarations:
❑1 haw and will maintain a Cemrnte of Consent in self-insure for Worlm''sCompen-
andon,as Provided for by Section 3700 of the Labor Code,for the performance of the
work for which this permit is issued.
I have and will maintain Worker's Compensation Intermix,an myuimd by Section
3700 ofthe labor Code,for the pamomance of the work rmwhich this permit is issued.
My Workers Gyp nFadorre+Insu�°nm camicr and Policy number am:
Cartier: ✓i MtLrVY+t0. Policy No.: 767
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE t
(Thu section need not W completW if the Permit is refuse hundred dollars($10(0
in less.)
1 certify that in the Performance of the work for which Nis permit is issued,l shall not
employ any person in any manners as to become subject to the Workers'Commendation
Laws of California.Data
Applicant
NOTICE TO APPLICANT:If.after making this Certificate or Exemption,you should
become subject to the Worker's Compensation previsions of the tabor CoW,you must
.JO forthwith comply with such provisions m Nis permit mol W Mimed rooked.
.'zCONSTRUCTION LENDING AGENCY
14 1 hereby arctrm that Nem is a convection lending agency I'm to perfurmenec of
!Yi s7 the work for which this permit is issued(Sec.H)97,Civ.C.)
W�Q Lenders Name
z Lenders Address
U 0 1 certify that I have read this application and soon that the above information is
I14 P come,.I agree in comply with all city and county mdinancm and son laws misting in
DU building convection,and hereby authorim representatives of Nis city to enter upon the
W shove-mentioned property,for indication Purposes.
y (We)agree to save,indemnify and keep humless the City of Cupertino against
VS liabilities,judgenewcosu no eapenes which may in any way accrue against mid City
.t)Z in consequence orthe granting of this Permit.
.. APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT Issuedby: Date
SOURCE REGU II�'ONS. � 41
-�^ Re-roofs
Signature of ApplicantiContramor Dia,
HAZARDOUS MATERIALS DISCLOSURE Type of Roof
Will no applicant or futon building occupant slam or handle havardon material
as defined by the Cupertino Municipal Code.Chapter 9.12.and the Health and Safety
dc,Seniors 25532(.)? All roofs shall be inspected nor to an roofing material being Installed.
❑Yet )eNo P P Y g $
Will the applicant or future building occupant use equipment or devices which If a roof is installed without first obtaining an inspection,I agree to remove
emit haxxrdnus sir emiuminants as dcfincd by the Bay Arta Air Quality Management all new materials for inspection.
District?
E]Yes
I have mad the hnardous materials requiromenu under Chaptarh.95 of the Coffin,
his HColth&SafmyCoac,S.m.25515,25533 and 25534.1 unacrsmna thati0he Wilding
docs net comedy hoe a¢nand.Net to u my rnponsihility la notify the occupant of the
raquiremcnts whichWmet p'n�rmp�i/ rci
nuance or a Cencate of cu cy. Signature of Applicant Date
`� h2t rO4
Owner or authornca agent All roof coverings to be Class"B"or better
pare