03100143 (2) CITY OF CUP);RTINO
BUILDING DIVISION PERMIT %iC()N:TRA,CTOR INFI�PIMATION
BUILDING ADDRESS: PERMIT NO,03100143 310Q143
.R'S NAME: PERMIT ISSUE DATE
E: SANITARY N0. CONTROL N0.
ARCHITEC(ENGINEER: BUILDING PERMIT INFO
BLDG ELECTPLUMB MECH
l� O 0 0
!00 LICENSED CONTRACTOR'S DECLARATION" Job Description
1 hereby affirm that 1 am licensed under provisions of Chapter 9(commencing
with Section nd of ser Division J of Ne Businesv and Professium Cnde,and my license is
a mmu.Class Jerred. ADD 295 SQ. FT.
cc in License Class
!C Dam ontr
CContractor
££ ARCHITECTS DECLARATION
i C U I understand my plans shall be used as public records
toa.G
y Licensed Professional
g OWNER-BUILDER DECLARATION _
S 1 hereby affirm that I am exempt from the Contractor's License Low for the
•
00 following mason,(Section 7031.5.Business and professions Cade:Any city or county
e$ff which requires a permit to construct,alter,improve,demolish,or repair any structure
prior In its issuance.also requires be applicant for such permit to file a signed statement
that he is licensed pursuant ns the provisions of the Contractor's License Law(Chapter 9 Sq. Ft. Floor Area Valuation
2 $ (commencing with Section)000)of Division 3 of the Business and Professions Code)or
Nm he is exempt therefrom and 1M basis for the alleged exemption.Any violation of 36923014 . 00
Section 7931.5 by airy applicant for a permit subjects Ne applicant to a civil penalty of11
am mare Nan five hundred delta.($50q). Occupancy Number Occupancy Type
❑I,as owacr of the property,or my employees with wages as their sol.compensation,
will do the work,end theaWCWreisnot intended oroRered for saie(Sec.]0a4,Business 'a !' I ,lRe uire'&Ins ec`t30nS
and Profession Code:The Conusucto's pply or License Law docs not aan owner q. P
property who builds orimpronis theman,and who docs such work himself or through his t
own employees,provided that such improvements are not intended craRemd for sale.If,
however,Ne building or improvement is sold wilhin one year of completion,the owner,
builder will have the burden of proving Nat he did not build or improve for purpose of
'-°'-
❑1,as owner of the ptopeny,am exclusively contracting with licensed contractors m
construct the project(See.7044,Business and Professions Cade:)The Contractor's U.
cense Law does not apply to an owner of propeny who builds or improves Nerean,and,
who contracts for such pmjccm with a contractor(s)licensed pursuant to the Contractors
License Law.
❑ I an exempt under Sec. B&PC or Ni reuan
r I Y.�i�/f 1 A(d Dra
ppr WOR R'S P NSATION DECLARAT�IOON�Nyaa
,11itmby aRrat under Penalty of perjury ane of the folkli.;;rclaratians:
1 haw and will maintain a Certificate of Consent to self-insure for Worker's Compen-
ntion,as provided for by genion 37M of Ne Labor Code,for de performance of the
work for which this patent is issued.
0 1 have and will maintain Workers Compensation Insurance,as required by Section
3700 of the Labor Code,far the performance of the work for which this permit is issued.
My Workers Compensation Insurance varier and Policy number are:
Carrier: Policy No.:
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(This seniors need not hccompleted if the Permit is for one hundred dollars($I00)
at less.)
1 certify thal in the porformanco of the work for which Nis Permit is issued,I shall not
employ any person in any manner an as In become subject to the Workers'Compensation
Laws of California.Date
Applicant
NOTICE TO APPLICANT:If,after making this Certificate of Exemption,you should
become subject m the Worker's Compensation provisions of the Labor Code,you mail
�z forthwith comply with such previsions or this Permit shall be deemed resulted.
ti O CONSTRUCTION LENDING AGENCY
ti FN., I hereby affirm Nn there is a construction lending agency for Ne Performance of
1a.� Ne work for which this Permit is issued(Sec.3097,CiN,C.)
LQ Lender's Name
z Lenders Address
;J Q I certify that 1 have read this application and sure that the show information is
(~' cored lag=to comply with all city and county ordinances and state laws relating to
7V building camsuand uctlon, hereby authmis rcpresematiws of or.city to enter upon the
N
'AT' shove-menti.ned property for hapectmn purposes.
ti (Wit)agree to save,indemnify and keep harmlass the City of Cupertino against
h
liabilities,judgment.costs and expenses which may in any way same against said City -
J.z in
APPLICANT of the granting of t
TUNDERSTANDSAND WILL COMPLY WITH ALL NON-POINT Issued by: Date
SOURCE LATIO
Re-roofs
S houncofApplicarounContolcuor Data
HAZARDOUS MATERIALS DISCLOSOPI Type of Roof .
Will the applicant or future building Occupant stare or handle locom ous material
as dented by the Cupertino Municipal Code,Chapter 9.12,and the Health and Safely
Seaton 25532(a)] All roofs shall be inspected prior to any roofing material being installed.
❑secs
41 Will the applicant or sewn building occupant use equipment or devices which If a roof is installed without first obtaining an inspection,I agree to remove
emit hvdrdous air contaminants as dcfned by the Bay Area Air Quality Management all new materials for inspection.
- District]
❑Yes S61Ju
I have mad the muni nm materiels requirements under Chapter 6.95 of the Califnr.
.in Health&Safety Code,Sections 25505,25533 end 25534.1 undersand Nat if the building
docs not currently haw a tenant,thm h is my maparadmility m notify the Occupant of the „
mquircmcn ichmustbc it'll"Oe ancyu3 Signature of Applicant Date
o@cyv
4r amhoriz agent Date
All roof coverings to be Class "B" or better