04110024 (2) CITY OF CUPE 't'RINO " `R
BUILDING DIVISION PERMIT �.CONTRACTOR`FINFQRMATION -
Mase
BUILDING ADDRESS: PERMIT NO.
ROY K KOZEN 04110024
OWNER' AMI: PERMIT ISSUE DATE
E: SANITARY OLNO.
ARCHITECT/ENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
0 0 0 0
u C b . LICENSED CONTRACT'OR'S DECLARATION lob Description
y u C 1 mm, of irm Nal l am limn d under Dmvisions of Chapmr 9(commencing p
b with Seetion]")of Division Sof Ne Busineuand limmaskuni Code.and my licwe is
5io in full fame and effect. -
�Rj License Class Lim.N REVISION--BEAM
^a Dam Contractor NO NEW PERMIT ISSUED ORIG. #04050155
ARCHn EC1'S DECLARATION
adIundcrsuce m
understand my plans ahallbeudu puhrecords
recordso REVISION--#04090271 - - - -
u t; Licensed Professional
a0< OWNER-BUILDER DECLARATION
1 hereby affirm that I am exempt from the Contractor's License Law for to
0 0 following mason.(Section 7131.5.Business and Professions Code:Any city or county
m which rtquires a pmmit to construct,alter.improve,demolish,or repair any structure
poor to its issuance.also myuims the applicant for such permit to file a signed statement
< that he is licensed pummmi to the provisions of the Contractor's Luxerne Law(Chapter 9 Sq.Ft. Floor Area Valuation -
'F0 (commencing with Section 7")of Division 3 of to Business=it Professions Code)or
y that he u exempt therefrom and ma buts for On alleged cxempeon.Any violation of
Section 7031.5 by any applicam for a permit subjects the apprcaul to a tial penalty of APN Number Occupancy ype
ant mom Nan five hundred dollars(5300).
I,as owner of the propcny,m my employees with wages as their sole compensation,
will do On warkand on,swctum ism,intended oraffered fersak(Sec.7W.Business 35701040 . 00
and Pnefessioru Coe:The Ommuco lis Lice¢Law dna amt apply was manor of Required Inspections
property who Wilds or improves thereon,and who docs such work himmlfor through his
own employees,provided Nat such improvements am not intended or offered for aide.It,
however.Ne building or improvement is mid within ore year of completion,the owner-
builder will pow the burden of proving that he did not Wild or improve for purpos,of
sale.).
❑I.as owner of the property,am exclusively contracting with licensed cmnuacbrs to l \
construct the project(Sec.7044,Business and Professions Crede:)The Contractor's U. - b
come taw docs not apply to an owner of property who Wilds or improves thereon,and Iw who contracts such protects aeomm�nor(s)licensed pursm ntnnh
uant the Coe
L
L'ce aw.
laman lexempt and sm. BhPCfor this moon u\
owner m
WO ER-SCOMP ON DECLA AT
I hereby affirm under penally of perjury one of the following declaration:
ham and will mmaConsent w
aim a Cenificab of Coeself-imam fur Worker's CW pem
ation,u provided for by Section 3]00 of Ne labor Code,for the performance of the
work for which this permit is issued.
❑T ban and will maintain Workers Compensation Insurance,u myuacd by Section
NW of Ne tabor Code,for the performance of the work for which this permit is issued.
My Workers Compensation Insurance artier and Policy number am:
Carrier. Policy No.:
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
Mss section need nutacomplcted if mW Permit is forme hundred dollus(S10(1)
or doss.)
1 certify the in the perforeamen of Ne work for which this permit is issued.I mail not
employ any inanymmner um WcomembjecumMWorem Compensation
Law fro*con Date
Applicant.L_ —•
NOTICE TO APP CANT:I(of making this Certificate of Exemption,you should
We subject b the Worker's Compensation provisions of the labor Code,you must
.J O Nwith comply with such provisions or this Permit shall W deemed revoked.
'Z CONSTRUCTION LENDING AGENCY
F4 thereby affirm that tam is a construction lending agency lot the performance of
(Y? Ne work fur which this permit Is issued(Sec.309].Civ.C.)
W A lender's Name
1 Lender's Addrrsa
U 0 1 certify Nat I have mad this application and sum Nat the mars information is
UL correct.1 agree in comply with all city and county eminences and sum laws relating in
V building consuvction,and hereby authodmrepmaemarives of Nis city to enter upon the
show mentioned property for soar edit r purposes
H O. (We)agree to says,indemnify and keep harmless to City of Cupertino against [ `/7�Iyt(y/5B` / .
y incoitieajudgmantsecostsand expenof Ous omay in anyway accrue against said City (/w'�J
fJz APPLI ANT Of UNDERSTANDS
of Nis Permit.
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT Issued by: Date
sou
RCER ULATI S.
Re-roofs
gnuum of IianOCen o Date
HAZAR US MATERIALS DISCLOSURE Type of Roof
Will we applicant or future building occupant store or handle haandous material
as defined by Jte Cup4rtim Municipal Code.Chapter 9.12.and the Halth and Safety
Cale.Section 255320>] All roofs shall be inspected prior to any roofing material being installed.
L
Yea on
Will Oc applicmt or future Wilding occupant use equipment or dcvica which If a roof is installed without first obtaining an inspection,I agree to remove
n hanmous air emnaminanu az defined by the Bay Area Air Quality Management all new materials for inspection.
D'urin]
O Yes 1No
1 have read the haramnursaraterials requirements under Chapter 6.95 ofthc Califor-
OieHealth&SafnyCode,Secdons 25505.25533 and 25534.1undersbmM thn ifde Wilding
docs not currently how a mount,east a is my resperuihility in nodfy Nc oceti are of the
mot: which ustbe tpriorWissuanccefaCcrefnv:mfOcnpamy. Sign atureofApplicant Date
// 3 u
ow era neomaagen Date roof coverings to be Class "B"or better