05030162 (2) CITY OF CUPERTINO :+�+ �• �`* "' •"w"'#"
BUILDING DIVISION PERMIT �,,CONTRAC R INFORMATION _
BUILDING ADDRESS: PERMITNO.
TERRA NOVA INDUSTRIES 05030162
OWNER'S NAME:. PERMUISSUBDATE
I
E:
SANITARY NCi. OL NO.
ARC HRECT,rENGINEER: BUILDING PERMIT INFO
BLDG ELECr PLUMB MECN
ao0 LICENSED CONfRACIOWSDECLARATION IobDescri [ton
C I hereby affirm that 1 am licvcd under provision of Chapter 9(commencing p
U wiOSccUm-7Og).f Dmisi n3ofdm Buairsss ProfcWum Cole.andmylicenwis
infmlforce and eff«I. /y(( o ��lF REVISION--ROOL UP DOORS & WINDOWS
D�? License Clazs Lc.N
Zrn Dam Contractor NO NEW PERMIT ISSUED/ORIG. #04100121
ti ARCHITECTS DECLARATION
s1 e i I understand my plans shall W coed u public records
7510
3u 1n Licensed Prefrommoal
OWNER-BUILDER DECLARATION
<I I hereby affirm Not 1 am exempt from the Contractor's License Law for the
00 following masa
on.(S0on 70313,Business and Professions Code:Any city or county
S:2� which requires a Permit to comark,slmr,improve.demORsh.Or.,air any snmcmm
m prior to its iuuance.alsu requires tbeapplikensforsuch Pcrmitto file a signedstamment
iia thatheislicensedpursuanofiepmvigmisifO.C.olmeno',Leto.law(Clopmr9 Sq.Ft. Floor Area Valuation
¢� pursuant
$ (eommemingwithSction1000)of Divumm3 ofthe Business and limfesdam Comm
.. that he is exempt therefrom and she buts for she alleged exemption.My violation of
Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of APN Number Occupancy Type
nos more Nan five hundred dollars(SSW).
❑1,u owrcr of Nc pmpenY.m mY employee with cages u Noir sole compensation,
will do Ne work,and theawcture is nosinuulcd or.Band fonale(Sec.J011,Busircas 3 1602104 , 00
and Professions Code:The Consmctors License Law doe not apply to an owner of Required Inspections
property who builds or improves timmon,and whodoessuch work himself orthrough his
hOwn owever.the ildingori improvement is
not oumdedmOBered for sola 1r- �\ -
bpwder the Wilding brimprovementissoldwithinane year of completion.Neowrcr-
Wo.).rwill have the burden of proving that he did not Wild or improve for purpose of \
Wo.). �J
Q 1,as owner of the property,am exclusively contracting wit licensed contractors to
construct Ne project(Sea 1011 Business and Profmsimns Code)The Camu ietorh Li
eme taw docs not apply to an owner of property who Wilds or improves Neuron,and
who commits for such projects with a consractems)licensed pursuant m the,Committees
Laciuc law.
❑1 our eempt under Sec. B&P C for this..on
who, Data
WORKER'S COMPENSATION DECLARATION
1 hereby a1Rrm under penalty of perjury ane of Ne following declarations:
h:m and will maintain a Cer ifiate of Commit to sel6imum for WmduhCompen-
on,as provided for by Section 3100 of the Labor Code.for the performance of the -
work for which this permit is issued.
❑1 have and will maintain Workcr's Compensation Imuran¢,as required by section
3100 of de labor Code,for Ne performance of the work for which this permit is issued.
My WOrkch Cnmpcn.5ationl sumnce carrier and Policy`num/bar am: �k �1
Carrier: 4 O Polity No ,k A!,
CB IFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(nils section need not bocompleted if the permit is forum,hundred dollars(SIM)
or less.)
I certify that in the performance of she work for which this permit is issued,I shall not
employ any person in any mann,Np aS�ybcpO a sunjcct to Ot Workers'Compensation
Laws of California.Da¢_!T/ / 7
Applicant i
NOTICE TO APPLICANT:It,after making this C,mificale of Exemption,you should
become subject to the Worker's Compensation provisions of the labor Codc,you muss
.J O foMwith comply with such provisions or this permit shall W dammed revoked.
z "" C0NSRtUC'nON LENDING AGENCY
[-.i0+ I hereby affirm Northam is a construction lending agency for the performance of
C> the work far which this permit is Wood(Same.3091,Civ.C.)
6W.Q Lcndcls Namc
�Z lender's Address
V Q 1 certify that I have read this application and suer Nat the above information Is
t" correct.I agree to comply wish all city and county ordinances and sum laws mlating to
O V building construction,and hereby aushods mpmsenutiaea of this city to enter upon the
t11 above-mentioned property for inspection purposes.
(We)agme to save,indemnify and keep harmless tW City of Cupertino against
Fh liabilities,judgments,tato and eapcmrs which may in any way..against said City
t)Z in consequence of thegranting of this Permit..I
^ APPLICANT UNDERSTANDSND WILL COMPLY WITH ALL NON-POINT Issued by: Date
SOU R UL >/
Re-roofs
are of ApplianUC ntr or Dam
H DOUS MATERIALS DISCLOSURE Type of Roof
Mllthcapplici orfusum Wilding Occupant snore or handle hvudou material
az dented by the Cupertino Municipal Code.Chapter 9.11,and the Health and Safety
Code.SectionC]y- [I No
Will the applicant or future building Occupant use equipment or device which If a roof is installed without first obtaining an inspection,I agree to remove
t hanrdous air contaminants u defined by the Bay Area Air Quality Management all new materials for inspection.
io?
❑Yes ❑No
Iban SgCLYC m.sechazardnuns 25505.2553als and nts255 1n Ice Chapmr6.9tofthe Wilding
riaHalN&Safer Codc.Satiom 25505.15533 azul ZSS3d.l unJerslvWlhuifNe Wi1Jin
dca not c my hue a tenant,Nat a u m mspamiMlity b notify Nc occupus of Nc
mqu, c hie m��'noo1 ccofaccnifiatonfoe ty. ignatureofApplic t Dat
caner ,Odaridagent Dow roof coverings to be Class"B"or better