04090230 (2) CITY OF CUPERTINO
BUILDING DIVISION PERMIT SGONTRACyTOR INFURMATION
BUILDING ADDRESS: HAMMOND CONST PERMR NO'04090230
Rs NAME: PERMIT ISSUE DATE-
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ATE
IfNE
GAIL PY
NE:
SANITARY NO. CONTROL NO.
ARCHCrECrfENGINEER: BUILDING PERMITINFO
BLDG EIECr PLUMB MECH
�Op LICENSED CONTRACnOR'SDECons of CON Job Descry
i w I hereby affirm that I em licensed under provisions orC.dc, 9(commencing FINAL
r
with Sermon7")of Division Sof Ote Brook..�JPmfessinna Code,entl myli cost is I{I1tS 4D9S�—'
-�_din mumne ntl ffe y D �� ADD, 144 SQ. FT. FOR DEN
Licenx Clus .Lic.N
=� Dale Convxmr rp-Nn
RCHI Cuss I �. 1004
.i I utMcrsunJ m Uv shall k used u is nxmds NOV" L
JiU
C t; LkcnxO Pmfcssionel ®®®
5 OWNER-BUILDER DECLARATION Q A
i<I 1 hereby affirm that I em eaempt from the Contractor License Low for the ByO/Np
p O following mason.(Section 7031.5,Business and Professions Codc:Any city or county
5..
NQ
991. which require It permit to consumer.alter,improve,demolish,or repair any svuaure
poor to its issuanee.alsurequires Ncapplicanl forsuch Pcnnitx Glc asigncdsmremem
�r< Our W is licensed pursuanuo Ne provisions of NC Cmumrm"License,Law(chapter 9 Sq.Ft. Floor Area Valuation
¢�$ (commencing with Section?")of Division 3 of Nc Business and Professions Code)or
- Out he Is eumpt therefrom and than buss for the alleged exmption.Any vialadon of
Section 7031.5 by tory applicant for a permit subjects lk applicant to a civil penalty of 31 219,41"er00 Occupancy Type
nor more Nen fin hundred dollars($500).
the
wok and
proputy,ar intended
orNwagu (Sm.
0".B Business will do Prfework ands: ewctumis pots Lirec0or awdrusnota(Sac.9004.Business .-
arta property
code:The commmors License Law dam not apply lf an owner ar Required Inspections
property who builds or reproves h rad who dao such work himself or through his
own employers,provided Net such improvements ere not intended oroWred for ade.envo r-
however,the buildingW improvement is sold within one year of completion,purpose
pose of
builder will have the Mrdcn of proving that he did not build or improve for purpose of ��,�t-� ��• �/' ]�����tl
sok,). s v k �,Ja' 1 q .
I,as owner of Oc progeny,am exclusively contracting wit licensed contrecmrs to
monomer.Lathe project(See.load,weer of and Ponfeproperty
who v Code:)The Convemon, n
c law doss rnot such pr je an owns of progeny who Milds or improves Ncrean,and
by market.for such projects wiNaeantrumKs)licenxdpursuam mlk Convadors —
aw.
esn ezcmpt under Set ,B&P C for Nis main
net Dat
WORKER'S COMPENSATON DECLARATION
I hereby stern under peentry of perjury ane of the following declualiou:
❑I haw and will maintain a Ceniflea¢af Covent to aelf-insure for Worker's Compen-
sation,u provided for by Section 37W of Ose labor Cade,for than performance of the
work for which this permit is issued.
I]1 have and will maintain Workers Compensation Insurance,az required by Section
37W of Ne labor Code.for the performance of Ne worst for which this permit is issued. `
My WWI,e Comreuatio�-Io ecaricr and Policy numkr are ,
Oaf: rex Policy N
CERT ICA OFEXEMPr10N ORKERS'
COMPENSATION INS ANCE - -
CITis section need not k completed if the Permit is for one hundred dollars(SIM)
or less.)
1 ons.)Nal in Nc Re ce of N ork for wh ch t Permit is issued,l shall not
cmPloy any personr y an pi
so 0the worts Com sation
Laws of r
Applicant
@IOUCE TO PLIC NT:If,a er making this Cem sate o xemptiy you should
More,subject m the Worker's Compensation provisions of the Labor Codc,you must
.JZ forthwith comply with such pnwisinv or this permit shall k deemed revoked. —
Z OCONSTRUCTION LENDING AGENCY
�--,� I hereby affirm that NCM iso construction lending agency lnr Ne performance of
QY> Ne work for which this permit is issued(Sec.3041,Civ.C.)
aQ lenders Nam:
Z Lenders Address
V O 1 comfy Nat I have mad this application and sum that the above mf rmutiun is
come,.1 agree to comply with all city and county ordinances and sure laws relating to
C V building construction,and hereby amilmim representatives of this city m enter upon th
r about-memiomed property fonvpeelm.Purposes.
(We)agree to save,indemnify and keep harmless the City of Cupertino against
U z liaclitiv.judgmcnu.cvuand ex nsuwhic Mayon anywayaccruc againstsaid City
in o
vryumm,of the grant this permi Issued b Da[
^ APPLICANT UNDERNT S S AND L COMPLY ALL NON- Iy;
SOURCEREGULATI ✓
/ n
Re-roofs
Signaw pp icanVC n b Da¢
HAZARDOUS MATERIALS DISCLOSURE Type of Roof
Willy the
Cupertino
tar fmur i buil 'ng uccupem tore or hanJie hazardous materiel
az defined by the Cupeninn Munici
Code.Chapter 9.12,and the Health and Safety
Conk,Section 25532(a)? All roofs shall be inspected prior to an roofing material beim
❑Yea Na40 P P Y g being installed.
Will the applicant or future Wilding oc vpant use equipment or devices which If a roof is installed without first obtaining an inspection,I agree to remove
emit hamdou air contaminants defined by Ne Bay Arca Air Quality Management all new materials for inspection.
District?
❑Yes Nu
I have mad Ne hvardous materials requirements under Chapter 6.95 of the,Califon
nia HcalNK Sefcty Codc v25W5.2 l33and2534.1 un�fe ddmif Ne Wilding
dons not currently hire nt,Nat it y responsibility Fn rymem pantnf Ne
myuiremcnts whigh at mat Price tasean=eora ce -t Signature of Applicant Date
\Xel / Y All roof coverings to be Class "B" or better
Owner or awhorind agent 6.m