04090043 CITY OF CUPERTINO c ' ��+}� �.T�.t - Tr
BUILDING DIVISION PERMIT Incl*JNPTRt�C'"TQRK
BUILDING ADDRESS: PERMIT NO04090043
0 4 0 9 0 0 4 3
n741 M WOT.PR Rn
OWNER'S NAME: PERMIT L6UEDATS
NE: SANITARY 0. 0 OL NO.
ARCHITBCTIENGINEER: BUILDING PERMIT INFO
p Bo o PLO o
+for Zp LICENSED CONTRACTOR'S DECLARATION
1 tomboy affrm that I am licensed under provisions of Chapter 9(consummating Job Description
with Section 1f0u)of Division 3of Ne Busineuand Proesstuns Code,and. lic,neis
In full fame and pm
LLiien Ctcla�jtc �.,ter INSTALL/^^2�`]STORAGE TANKS
3 s / ARCHRELTS DECLA ATION ��--
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Licensed Professional (•/ v �� /' '":"A
3 OWNER-BUILDER DECLARATION
I I hereby amore uses I am exempt from tiro Conuemars License law for the
O O following region.(section 7131.5,Business and Professions Code:Any city at county
$ which requires a permit w construct.altar,improve,demolish,or repair any structure w
Puorth missuance,aha requires lM applicant farsuche permitw Okasignduaumcnt
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that he is licensed pursuant to the Provisions of the Contractors Littnm Law(Chapter 9 Sq.Ft. MoVArea „� `��,� Valuation
63$ (commencing with Section 7000)of Division 3 of the Business and Professions Code)at `
3 Nat he is exempt therefrom and Ne basis for The alleged exemption.My violation of
Sections 7031.5 by airy applicant fan permit objects the applicant to a civil penalty of APN Numberan
cu V O' e e
not mom than five hundred dollars($501G.
fC)s P yTyp
❑I,giowouafthe propmy,ormy wployw with wgn at their sole eompenution, ) /l
windothe work.and thsuructure is out intended anEerd forsale(Sec.7044,BummsaRe uired Ins BC Tanis
and Prosed..Code:The Commerce.Lt.=Law does not apply N an owner of q p
property w ho buRdmr i m prov Merton,and wh o does such work himself or through his
own employers,provided Nat such improvemenuase notimmndd orolfartd foraale.It, /
however,Ne building or improvement is mid within on you of completion,the owmr-
builder will have the burden of proving that las did ant build or Improve for purpose of
❑1,as owner of the property.em conclusively contracting with Ilcenud contractors N
constroct the project(See.7041,Business and Professions Cade:)The Contracuri Li. -
comem Law dors red,apply to an owner of property who builds or improve the.un.and
who contracts for such projects with acontnctor(s)licensed pursuant to Ne Commerce,
U."m law.
E]I un exempt under Sec. ,B h P C for this mason
Owner Data
WORKER'S COMPENSATION DECLARATION
I hereby affirm under penury of perjury one of the following declaration:
I have and will maintain a Ccntfiate of Consent toselfdnsum for,WerkeesCompen-
aging,as provided for by Section 3700 of time labor Case,for the parformeece of the
work for which this permit is issued.
1 hoe and will maintain Worker's Compensation Irtwrance,u required by Section
3700 of Ne labor Code.for Ne performance of Ne work for which Nis permit is Issued.
My Worker'.Compensation Insurance catricr and Policy number art:
Cartkr �Iyl ia�po cy "
CERW9 ^OFaKEMPnON FROM WORKERS' ,
COMPENSATION INSURANCE
(11th motion recd trot betcomplemd ifft permius fortune hundred dllua(SIM)
or lean)
I unify that in tied performemo of tie work for which this permit is issued,1 Nell nm
employ any person In my mamrse u N beam,object to he Worhri Compensation
NLava of CJlif i
OTIC (��
NOTICE A heWoul IL after musing his inions of of Exemption,you should
become subject y the Woh provisions
roCompewtion provisions of the cleared
Code,you muss
OfaMwiN comply with merit prnvirions m this permit M domed rtmkce.
Z y CONSTRUCTION LENDING AGENCY
Fr Ihereby urn.that there its conulending ructinn lendingency for the performance of
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> the work for which thus perrelt us issued(Sec.3097.Co,C.)
Q Larches Nurse
J z Lenders Addreas
U O 1 cerffy that I have mad this appikadon ad sum Thu the above information is
ly V conccL I agree to comply with all city and county ordinances and sum laws miming to
O building construction,and hereby auinume,representative of his city us color upon fed
W alcove-memioned property for inspection purposes
[yam,p3. (Wer)agree to give,indemnify and kap harmmm the City of Cupertino against
Ilabilides,judgments,costs and expenses which may in any way aam,against mid City
C)? in APPLLIICANT UNDEuenof the RSTANDS Awuof IND WILL COMPLY WITH ALL NON-POINT' Issued by: Date
SOUR E IlEqK600N
54
Re-roofs
reol'Ap inn .r Da
HAZARDOUS MATERIALS DISCLOSURE Type of Roof
Will the applleant err(.are building oceupmt 31ort arhaaslc lommoloa maurial
at defend by the Cupertino Municipal Code.Chapter 9.12.and the Health and Safety
Code,Section 25532(x)? All roofs shall be inspected prior to any roofing material being installed.
0h.
Ya
Will the applicant or future building Occupant um equipment or devices which 'If a roof is installed without first obtaining an inspection,I agree to remove
6 havandoa gir.manelmou as#11red by the Bay Area Air Quality Management all new materials for inspection.
District?
El Yes u
I have mad the haranww meloriusrequirtmanu under Chapter G95 crude Califor.
nia Huth&SafmyCde.Sectiam 2505.25533 and 25534.1 uncessund thu ifde Wilding
Jas no concntty how a lenms,that it is my responsibility ed notily the arupans of an
comm entaw
be rwissuaeccafaCcniOcamofOcu e. Signature of Applicant Date
i
go�,T�,uthedag���`!"�— Dam
All roof coverings to be Class "B"or better