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CITY OF CUPERTINO
TRACTOR INk'ORMA"C'IUN
BUILDING DIVISION PEIRAHT
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BUILDING ADDRESS:
Z M GENERAL CONTRACTOR INC
"""T"005060102
OWNER'S NAME:
PERMIT ISSUE DATE
SANITARY NO. CONTROL N0.
(415)585-1823
ARCHrrECTIENGINEER:
BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
LICENSED CONTRACTOR'S DECLARATION
Job Description
by affil at 1 am licensed under provisions of Chapmr 9 (cemmaeing
1 herem N
with Station 70018 of DivWan 3 of the Business And Profcasues Code, and my license u
inmRforwwdeffcn
DEMO (E) HOUSE
License Class Lie. R
Dam C..o.wr
ARCEI TEC'S DECLARATION
I understand my plans shall W used As public records
Licensed Professional
OWNER -BUILDER DECLARATION
I W Mhy arfilm that 1 am nempt from Ute Contractors LIMO= Law for Me
fallowing mason. (Section 703 1.5, Business and Professions Colo: My city w county
which wipures a permit In construct, atter. improw, demolish, or repair soy mucture
$7500
prior in its iuumce, Wu requires the applicant for such permit in nic asigaA suwment
Ft. Floor Area
Valuation
Mal he is licensed pursuant to the provisions of the Conmcwrs license Law (chortler 9
Sq.
(commencing with Section 7000) of Division 3 of Me Business and Professions Code) or
that he is exempt therefrom and tie bash for the alleged exemption. My violation of
Occupancy Type
Section 7031.3 by any applicant for a permit subjects Ne applicant to a civil penally of
AM mom Nan Bw hundred dollen ($500).
❑ T.no ofthepmprny,ormyemPloyemwithwgesutetrwlecmnpmwon,
Required Inspections
Mll eco thewark and theamYctum ism, lmmidedoraRered lonale(Sm. 70", Basineu
and ProresUalu Code: The Commiserates License Law don net appy w an Owner of
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property who bu Ilds or im pram Neuron, end who da, such work himsel f orNrouSh his
own emptoyrss, provided Nal wch improwmemu art m,inwnded noffaed fwsaw. IL
however, Ne building or Improvement is sold within ons year of oemphown, the eweve.
Wild" will haw the burden of proving that he did ser Wild or improve for puts= of
mit.). .
V. as Owner of Me property am exclusively contracting with licensed oomncws w
construct the project (Sec. 7044, Business and Profession Code:) The Coutracce's Li-
cense Low docs not apply to an owner of property.whe Wilds or improv demon. and.
who contracts for such projects with a comtrwlar(a) licensed pannnl or Ne Contractors
License law.
0 1 am exempt under Sm. B A PMIACC for threason
0
Owner WORK 5 TION DECLARATION
I hereby afnrw under penalty of perjury one of Me following declarations
haw and will maintain • Cenincamaf Covent w self -imine for Wodwrs Compen-
sation, As provided for by Section 3700 of dm lobar Code, for the performance of Mo
work for which this Permit is issued.
❑ 1 haw and will maintain Workee, Compensation hMstuance, As required by Salton
3700 of the Lata r Cade, for the perfarmaxe of tie wart for which this permit is issued.
My Worker, Compensation Insurance carrier and Policy number are:
Carthr. Policy No..-
o.:CERTIFICATE
CERTIFICATEOF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(This axticm reed notbccmnplewd toren powl is forone hundred dollars(5100)
or ism.)
I certify Mot in Me Performance of Ne work for which this Permit h issued. l Nall not
employ anyf in soy manner >�wh c ejnl to the Worken'Cmnpenu0on
'
Laws of Celife n
I
AppnemmrJ'�fm^'�+r L4S�.-j—
NOTICE TOA : If. After making this CeniOnm of Exemption. you should
become subjw w Me Worker's Compcnuuan provisions of we IoWr Code, you miss
forthwith comply with such proveliov or this permit shall be named reviled.
CONSTRUCTION LENDING AGENCY
1 hereby.m. that Mem its construction hndlngagency for Me performance of
the work for which this permit Is issued (Sec. 3097, Civ. C.)
Lenders Name
,
Lenders Address
1 ceNfy, that I have read this appncsion and sum that IW move Information Is
'
comm I agree to comply with all city and county oNimneea and sum levo minting in
Wilding construction, sed hemby awhadw repesenutiv of this city to enter upon the
mane -mentioned property for inspection purposes
(We) agree to taw, indemnify and keep harmless the City of Cupertino against
liabilitiea,judgmtenu, costs and exavn which may In my way acerae ogalmusald City
In consequence of the Beaming of this Permit.
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON -POINT
Issued by: Date �� 1f-10
SOURCE of LATIO
Re -roofs
RM 0 S-
Signuum Appli Dow
of onmactor
ARDOUS MATERIALS DISCLOSURE
Type of Roof
Will Ne applicant Or future building Oceupsmt sane Or handle hudrdam mawdal
As defined by the Cupertino Municipal Cade, Chapter 9.12. and the Health and Safely
Code. Section 253320)7
Oyes 6.
All roofs shall be inspected prior to any roofing material being installed.
If a roof is installed without first obtaining an inspection, I agree to remove
Will Me applicant at macre building Occupant use equipment or dean, which
hazardous aircanuminanu As defined by Me Bay Area Air Quality Management
all new materials for inspection.
.islet? �/
❑Yat 2<.
I have mail the hmndmes Materials requirements underChipwr 6.95 of Me Califar.
nia Health @SafetyCode, Sections 25505,25533 and 25334. 1 undenwnd Mu if Oe building
does sol currently haw a wnmr. that It it my reapovlhillly w nadl'y Ne ma:upml of the
nitureme whim mustWm pdorwissumceofa Ccninc,in face I.
Signature of Applicant Date
DDam
All roof coverings to be Class "B" or better
Owner
or authorised nt