05030177 (2) CI TY OF CUPERTINO +'
BUILDING DIVISION PERMIT A,CO,NTRACTnRINF.URMATION
BUILDINGADORESS: PERMIT N
WEST COAST DEVELOPMENT 05030177
4-1 rT.T7!NrQE DR
OWNER'S NAME: 7E LSUE DATE
SHUT LTU 941';1; ALMADEN RXPW34
122/2
NE: SANITARY C OL NO.
ARC HITECIPENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
0 0 0 0
Pipe LICENSED CONTRACTOR'S DECLARATION Job Description
C 1 hereby affirm that 1 am licensed under provisions of CMpar 9(commencing
b with Section 7")of Division 30844 BusiricssaM Profesriorta Code,and mylicc=13
in full to=and effect. 'a REVISION--IN HOUSE USE ONLY
S Y�? License Cl LM.N
o Dam c°nuacmr - NO NEW PERMIT ISSUED/ORIG. 404110107
�',fi l ARCHfiCTSDECLARATION
yt undcrsmnd my las sh xJ nc records
=y OWNER-BUILDER DE Ce RATION
20 I hereby maso affirm Nat 11. anoint from the Contras Cod License Law for the
po followwhich
naxna Permit ](D1.5,Businessand ve,do u)i Ca de:Any City mroomy
m which reyuifG a c.also ru comaluims,do,,alcor-improve,h Permit t orrepairpair any structure
prior s,its issuance,pursuant
nt to the the applicant for such pcnnil m rite s signed stammem
I?C
(dust commencing
cing wit pursuion70(theprovisionDivionso of t Contrition's lxcnulaw(C odc)or Sq. Ft. Floor Area - Valuation O
a, (commcnc onsortbherefrom and
of Division3 de,al Business and Profusions Codc)of
that he u consort therefrom and Ue bus for the alleged exemption.Any violation of
Section 1031.5 by my applicant for a permit Mbjects then applicanuo a civil penally of APN Number Occupancy Type
not mom than five hundred dollen DS B. _
1,u owner of the property,or my employee with wages u their In compenutlan. 32630107 . 00
will do the work,and the a nadme is not intended oroRered for sale(Sec.1044,Business
and Predecdots Code:To,Con isctoes Linense,law dens not apply in an owner of Required Inspections
propeny who builds or improves themon,and who docs such work himself or through his
Own employees,provided Iho such improvements art not intended or offered for sale.IL
however the building or improvamam is old within one year of completion,Ne owhu.
Wilder will ha ,the burden of proving that he did not Wild or improve for punpux of
satin.).
FI 1,as owner of de property,am exclusively contracting with licensed ennua dun In
consuvct the project(Sec.1(144,Business and Pofeadota Cade:)Th Cont acwr's Li-
ecrom law docs not apply in an owner of propcny who Wilds or improves Demon,and
whocontracts for such projects with a contrxmogs)licensed pursuant me the,Contrumr's (\—
LicensenseLalaw.
❑ lam ezempm under Sec. ,B&PC for this rtann O
Owner Date I
WORKER'S COMPENSATION DECLARATION a,
I hereby air=under penalty of perjury one of the following dalmtiou: �
I have and will maintain a Certificate of Consent to self-insure for Wo6ker's Compen- /
sation,an provided for by Section 37M of the Labor Code.for one performance of the
work for which Nis permit is issued.
1 have and will maintain Worker's Compensation Insurance,as required by Section
3700 of the labor Code,for the performance of the work for which this permit is issued.
My Worker's ComPensatio Iesunna ranter and Policy number tic:
Carrier.U / Polity No.:��
CERTIFICATE OF EXEMPTION FROM WOR E¢5'
COMPENSATION INSURANCE •-PY10. Y
(This action need not W completed tribe Permit u forane hundred dollars($IM)
Or lrss.)
1 certify that in Ne performance of Ne work for which this permil is wood,1 Nall not
employ any person in any mann,,so is to baame svbjal to the Worked Compcuauon
La.s of California.Da¢
Applicant
NOTICE TO APPLICANT:IL aper making this Ccni!cam of Eamption,you should
become Subject in the Workers Comprnsauon provisions of the,labor Code,you most
.JO foMwilh Comply with such provisions or Nis permit shall W decreed revoked.
Z� CONSTRUCTION LENDING AGENCY
[-+ thereby aMom that Nen iso summation lending agony,lot the performance of
a the work for which Nu permit is issued(Sec.3091.Civ,Cd
tk1 Q lender's Name
Z) z lender's Address
U C) I ennify that 1 have read this application and some that Ih,aWve information u
k.f" coact.I agree to comply with all city and county ordinances and sum laws rusting to
OU building construction,and hereby authorim opresematives of this city to enter upon the
rCU move-mendoned pupcny for iupeefion purposes.
(~C (Wed agree to save.indemnify and kap harmless the City of Cupertino against
to liabilities,judgments,costs and expenses which may in any way scctuc against mid City
U Z in consequence of the granting of this perm' ��
^-� APPLIC UNDERSTANDS AN ILL COMPLY WITH ALL N -POINT Issued by: Date
SOUPICSREGULATIONS.
3 � Re-roofs
i "f Applican I'dor m
AZARGOLIS MATERIALS DISCLOSURE Type of Roof
Willthe licamor future building occupant start of bandlc havudous material
' a defined by the Curanino Municipal Code.Chapter 9.12,and thc Hcalth and Safety
Codc,Section 25532(a)? n All roofs shall be inspected prior to any roofing material being installed.
Yea
Will the applicant or future building Occupant use equipment or dcvicu which If a roof is installed without first obtaining an inspection,I agree to remove
it hazardous air contaminants u defined by the Bay Arta Air Quality Management all new materials for inspection.
iWicl? (/
❑Yea MByI11
1 have mad the hanrdnusmamriuls requiremcnu under Chapter 6.95 of tic Califor-
�o.t
afe,Code,Secucu25505,25533 im1255M.lundcrstand the ifde Wilding
nuy hens,a emank Nam it' miponsibility m ntify de upant f the
whichmuslWmc nSIDanrepflcerbficampfDcr anrr. Signature of Applicant Date
OS
r aulhAll roof coverings to be Class"B"or better
ari'rc '/ ale