04060077 (2) CITY OF CUPERTINO uhf
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BUILDING DIVISION PERMIT CONTRACTOR INFOMATIO.NK��,.
BUILDING ADDRESS: """'04060077
ERMIT NOO 4 0 6 0 0 7 7
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OWNER'S NAME: PERMIT ISSUE DATE
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SANITARY NO. CONTROL NO.
ARCHITECT/ENGINEER: BUILDING PERMITINFO
BLDG ELECT P0LUMB MECH
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v00 LICENSED CON RACIOWSDECLARATION Job Description
y. 1 hereby affirm that I am licensed under provisions of Chapter 9(commencing P
with Section TMOd i f Division S of Je Busineuand Professiom Code.and my license is
"�N in pull to=and cricet. NEW SECOND UNIT (563 SQ. FT. )
j vvj? License Class Lk.g
r O Date Contractor
w ARCHITECTS DECLARATION
1 undersand and,plans shall W used as public rocords
JtoU
ipr^ Licensed Professional
3 OWNER-BUILDER DECLARATION
<� 1 b rchy affirm thll 1 em cxcmpt(man the Contractor's License Law for the
00 following reason.(Section 7031.5,Business and Professions Code:Any city or county
K m which nquime a permit an cnaamct,alum.improve,demolish,or repair any structure 000
yzi prior to its issuance.also requires the applicant for such Permit to file a signed statement
< that he is licensed pu.uanllonCprovisions ofOcCommon''sLiccnacLaw(Chapter 9 Sq.Ft. Floor Area Valuation
,Fe (commencing with Section 7")of Division 3 of the Business and Professions Maim
Valuation, OR he is tempt dereism and tbe bazu for the alleged cmmplion.Any violation
Section 7031.5 by any applieam for a pemtit aubjecu the applicaet ao-civil penalty r er0 0 Occupancy Type
not mon than five hundred doll..(SSM).
��$'1,asowner ofthe paoen
py,or my employee with wages id;Weir aole mauncrsiumn
Zardo the work and thesarunure is not Intended omoBard forsale(Ser.70".Baainess
and Professions Coda:Toe ContmnorS Li..Law ducts, at apply an an owner of nFr /Jr 2OU4 Required Inspections
property who builds or improve thereon,and who dons such work himself or dough his
Own employers,provided that such improvemomts are notinundeu or offered for We.If,
however,the building or improvement is sold within one year of completion,the r�ow5�ncr-
builder will have We burden of proving that be did nm Wild or improve fur ptMaS LD
q ,r
sale.he U I�ION`pJl
C)I,as awncr of the property up uelusively contracting with licensed con ti, ,
construct the project(Sec.7044,Business and Professions Cade:)The Contractor's Li.
come Law dors not apply W an owner of propcny who builds or improves thenen,and,
who contracts for such projects wish acom.aor(s)licensed pu.uan to the Contractor's
LKCnse Law.
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Isexempt rose ` B k P C for this rcazon
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WORKER'S COMPENSATION DECLARATION
1 hereby affirm under penalty of perjury one of the following dalaations:
have and will maintain aCeniOore of Consent to self insure for Worker's Compen-
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,a provided for by Section 3700 of one IaWr Code,for the performance of the
for which this permit is issued.
have and will maintain Worker's Compensation hodrnaa,as equiwd by Section
ofWe tabor Codc,for the performance of the work for which Wis permit is issued.
orkers Compensation Insurance carrier and Policy number ere:
( Cariee Policy No.:
f" CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(Thisseamon need not becwnpleud if the permit is(mane hundmddollars(SIM)
or lase.)
1 certify that in the performance of Ne work for which Wis permit is issued.I shell not
employ any pawn in any manner so a be become subject to she Workeri Campewtion
Laws of Califomia.Dau
Applicant
NOTICE TO APPLICANT:If,after making dos Cenifeae of Exemption,you should
become subject ro We Worker's Compensstion provisioru of the IaWr Code,you most
0 O forthwith comply win such provision or this permit Wall be deemed revaked.
Z"' CONSTRUCTION LENDING AGENCY
PI hereby affirm that then is a construction lending agency for the Performance of
C4 the work for which this Permit is issued(Sec.3097,Civ,C.)
[[7 lender's Name
C Lender's Address
az
U 0 1 certify Nat 1 have mad this applicaion and sum that the above information is
contact.1 agree to comply with all city and county ordinances and star laws elating to
DU Wilding Coruscation.and herebyaahadn epoesenutives of this city to anti upon thc
r W strove-memioned property(m inspection purposes.
y (We)agree to save,indicatory and keep harmless the City of Cupertino against /
FLiabilities.judgments,costs and expenses which may in any way accrue against said City
U Z in consequence of the granting of this permit.
^ APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT Issued by:9 Dat
SOURC_T__ 1 - S. 1 v '7/ 1'n r �
W 1 V�- Re-roofs
Signature of AinibeanJContmcmr Dau
HAZARDOUS MATERIALS DISCLOSURE Type of Roof
Will the applicant or future building occupant store or handle haeNous material
az defined by the Cupertino Municipal Code.CTapur 9.12.and the Health and Safety
Code,Section 25532(a)? All roofs shall be inspected prior to any roofing material being installed.❑Yas No
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
havadous air contaminants as defined by Oc Bay Area Air Quality Management all new materials for inspection.
via? 1
❑Yes AN.
1 have mad the Wmrdcus materialsequimments under Chapter 6.95 of rte Califor-
niaHcalnkSafctyCede.S U=25505.23533and25534.1uode.undW ifbe Wilding
does not currently have.umam that it is my espomibilay In notify the ersup.,0 Jrc
mqui me its to et prier to issuance of aCemnicauofOccapan . Signature of Applicant Date
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Owner or aumorind agent Date All roof coverings to be Class"B"or better