05010151 (2) CITY OF CUPERTINO s �r �. ,aY» •"` a^t � •.:'.
Bq" DIVISION PERMIT ONrTRACTOR-yINF.ORMATION`'t4
BUILDNf GADUkESS: YANG GENERAL PERMIT NQ 5010151
ER'S NAME: PERMIT ISSUE DATE
PHONE: SANITARY NO. CONTROL NO.
(408) 398-4209
ARCHITECflENG1NEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
,1 'z LICENSED CONTRACTOR'S DECLARATION O O O
jwC I hcaby affirm that I am liamed under provisions of Chapter 9(commencing Job Description
iW wish Section 7")ofDivision 3 ofthe Business anal Prtufcsslom Code,and my license is
infull mueand erect
j.e c, Licenu Class LL..N REVISION- -IN HOUSE USE ONLY
4�n Date canaaeser NO NEW PERMIT ISSUED/ORIG. #04110169
ARCHITECTS DECLARATION
wU I understand my plans shall Mused as public records
it
. G� Licensed Professional
3 OWNER-BUILDER DECLARATION
.� f I hereby al0rm that 1 am exempt from the Contnant's License Law for the
°0 following mason.(Sectio^7031.5.Business and Pmfcsakma Code:Any city or county
$�a which requires a permit to enrraun,alter,improve,dorolish,m repair any suuauu
bileprior In is issuance.also requires the applicant for such permit m Glc a signed entemont
NasiM is licensed Pursuant to the provisions ofshe Connector's License Law(ChaPter9 Sq.Ft.Floor Area Valuation $0
(commencing with section 111W)of Division 3 of Business and Professions Crude)or
i $ that he is exempt therefrom and the basis for the alleged exemption.Any violation of
Section 7031.5 by any applicant foe a permit subjects the applicant so a civil penalty of APN Number Occupancy Type
not mom Nam five hundred dollars(ss L 32633013 . 00
p y yp
❑I,u owner of the property,or my employees wish wages u their tele compensation,
will do be work and dte swmum u not intended Wi ffmad for sale(Sec.1016,Business
and Rofeasiam Cade:The Contractor's License Law does net apply to an owner of Required Inspections
isminny who builds orimpraves thereon,and who doessuch work himself or Enough his
awn employees,provided that such improvements are not intended or offend for sale.If,
however.or wilding or improvement is sold within One yea of completion.Ne owner-
Will.,will have dte wreas of proving Nat M did not wild W Improve rap purpose of
ate.).
co 1,u l the of the pm.7(Pk,B exclusively crooning wish licensed mmrumss m
corse La du es net (Sect ad Business and property
he
Code:) po Conuumts Li-
cense law dos not apply a an owner of pmpeny who wilds or improves Ci um rd
who recm(rr such projects wit aconuacmr(s)licenud pursuant mNe Ctunuemoh �1
LKCOY JW.
❑ lam exempt undo See. .Bk PC fm this moon \
er Date
WORKER'S COMPENSATION DECLARATION
1 Mmby affirm under penalty of perjury one of the following dedantioa:
I have and will maintain a Certificate of Consent to selbinsum for Workcls Compcm
sation,as provided for by Section 3100 of the Labor Code.for she Performance of thc
work for which Nis permit is issued.
❑ I have and will maintain Worker's Compensation Insurance,u required by Section
3100 of the Labor Code,for the performance of she work for which his permit is issued.
My Workers Compema ion Insurance carrier and Policy number se:
Cartier. Polity No.:
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(Thu uetim need not M completed if da Pamir is Fortune hundred dollar(SIM)
W lax.)
I eenify that in the performance of the work for which this Permit is lesson,I shall not
employ any PCROn In any manner so as ka become subject to ft WrkLfi GOmpamfion
Laws of California.Date
Applicant
NOTICE TO APPLICANT.If.after making Nis Certificate Of Exemption,you should
become subjen no she Worke6 Compensation previsions of tM ISMr Code.you comm
.,O foMwuh comply with such provisions or this Permit shall W deemed revoked.
Z CONSTRUCTION LENDING AGENCY
[-+ I bemby a Rum Na Neu its corumetion lending agency or she paformamx of
rG tite work for which this permit is issued(Sec.3091,Civ.C.)
V.1 Lenders Name
D. Lenders Address
oz
U Q 1 certify that I have mad this application and sou Nat the shorn inimenatim is
Iy Hcomet I agree to comply with all city and county ordinances and state laws relating to
�U building construction.and hereby aurhmiu repraenutivns of this city to enter upon the
r W
above-menuorold pmPeny farinspection purposes.
(„m y I We)agree to save,indemnify and keep harmless the City of Cupertino against
Z liabilities.judgments.ftheeoBand expenses which may in any way ucruc against Mid City
U z APPLICANTeUNDERSTANDS Athis
ND WILL COMPLY WITH ALL NON-POINT Issued by: Date
SOURCE REGULATIONS.
Re-roofs
Signature of APPIiwDow
HAZARDOUS
US MATERIALS DISCLOSURE Type of Roof
Willt applicant or forum ng buildioccupant ram ar handle h eaAous material
defined y ie Cupertino Municipal Code,Chapter 9.12,and the Health and Safety
c.Sccure shn 253324)?
❑Ya ON. All roofs shall be inspected prior to any roofing material being installed.
Will thea applicant or future Wilding mcr ant vie equipment If a roof is installed without first obtaining an inspection,I agree to remove
pp g p y it Qu or Marta which g
emir bmvardnus air contaminants a Jc6ncJ by be Bay Area Air Quality Management all new materials for inspection.
Diuict? �5
❑Ya ❑No
I have read the bmaNmus materials requirements under Chapter 6.95 of the Califor
nia Halthh Safety Code,Somans 25505.25533 sal 25536.1 undreamed the,if du wilding
does cot namntiy have a tenant Nat it is my responsibility W.61,tite occupant o1 Ne
requirements which Must xMet prior In issuance nnCemfiateoracapamey. Signature of Applicant Date
Owner Or aushorind agent Dae All roof coverings to be Class "B"Or better