02110123 (2) CITY OF CUPERTINO �L* ,
BUILDING DIVISION PERMIT 'CONTRACTOR INF,OAMATION ,r
BUILIMS[ BIIESLOREE AVE. PERMTTN(02110123
OWISM N,A']II:NH LU APPLICATT1SIAY UY 2 0 0'2
OkiONE: SANITARY NO.'' `` // CONTROL NO.
PH
ARCHITECT/ENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MF.CH
0 0 0 0
�00 LICENSED CONTRACTOR'S DECLARATION On
I�- I hemby affirm that I am licensed under provisions of Chapter 9(commencing UPG E JG C V 1
with Section 7000)mf Division Sof the Busitmssa lProfessi Professions and license is
0 infauroacand effro. / -7 o� C NT D ' REDD BUILDING
O�' Ch Lic,g a 2$nyDare ( meadCona,curtARCHITECTS DECLARATION01 unJernad my plansshall be used m public rccnrtls
O U
t3a Licensed Pngcasinnal
t
l� OWNER-BUILDERexemptO[Ce Contractors
OX 0 1 heresy.Sect Ism I oro exempt from the Corions Code:
:Anne Law for the
iii 00 following reason.(SCetiOo 7(DLm Business and Professions h.or:Any city n,county
a�$ which requires a permit re consumer,the alter.improve.for such
demolish, file
repair any structure $500
F Z>• pnomnits censed palm requires lhovisio s(if for the Contrarmiunfiants,Law
mem
s< (com islicensedwith
pursuant tion70the pmvivionso of
Bsinesssnd Professions
(C ode)9 Sq. Ft Floor Area Valuation
W F$ (commencing its Sen,from and the
Division r the
the Rosiness prion.fAny vi Cade)of 37513025 . 00
that he is exempt therefrom and Ne bazis for the alleged exemption.Any violation of
Section 7031.5 by any applicant for a pemlit subjects the applicant to a civil penalty of APN Number Occupancy Type
not more than Eve hundred dollars(SSW). 103 — UFER
❑Lu owner ofd¢pmp,ny,or my employees with wages in Heir sole compensation,
will do In,work,and the immune is not intended oroffered forage(Sec.7094.Business 364 ReydE31ggppB1�yy{{ ppg Ab
and Professiom Com:The Contractor's License law does not apply to an owner of 5 0 5 — F I NAL 1sGk-, y kPyJ,y ODs
pmpenY who builds or improves thereon,and who does such work himulf or through his
own employees,provided that uch improvements meant intended oroffered for uta If.
however.the building or improvement is mid within one year of completion.the owner
builder will have the burden of proving Nat he did not Wild or improve for purpod of
sale.).
❑I,as owner of to property,am exclusively contracting with licensed contranoi to
construct the project(Sec.7(WBusiness;and Professions Code:)The Coutncmr's Li.
coma law does not apply to an owner of property who Wilds or improves themon.and
who comment for such projects with a connactor(s)licensed pursuant to the Contractor's
License law.
❑ I sum exempt under Sec. .B&P C for this recon
owner Dow
WORKER'S COMPENSATION DECLARATION
1 hereby nation under penalty of perjury one of the following dlan
ections:
I have and will maintain a Certificate of Cerium to self-insure m
fnr Worker's Copere
1371M
ion,u provided for by Section 37W of the labor Coda,far the performance of the
rk for which this permit is issued.
1 have and will maintain Workers Compensation Insurance,as required by Section
of Ne laWr Code,for Ne performance the of work for which this permit is issued.
y Worker's Compensation Insurance carrier and Policy number are:me,: Policy No,
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
GrInswetion need not becompleted if the permit is forms,hundred dollars(51X7
less.)
I certify that in the performance of the work for which this permit is issued,I shall not
employ any person in any mannersq a/ tMe sing',inthe Workefs'Compensation
w
\ LBsof California.DmI // D L
Applicant �I r, tY
NOTICE TO APPLICA :If.after making this Ceniacate of Exemption,you should
become subject to the Worker's Compensation previsions of the Labor Com,you must
OO forthwith comply with such provisions or this permit shall be Jexand revoked.
CONSTRUCTION LENDING AGENCY
[-+ 41 (hereby affirm that there is a construction lending agency limhe performance of
6i 7 the work for which this permit is issued(Sec.3197.Civ.O)
Igl 0 Lender's Name
11 Lemderi Address
V 0 1 certify that I have mad this application and mile that the above information is
U. building I egret to comply were all city and county ordinances andante laws relining it,
o
imovengcltioned construction.and hemhyeuNonprposesenntives of Niscity to enter upon the
aWve-me e)agree
Cols ve for inspection
mnify an weir hv.
L}�t, (We)agree to save,indemnify and keep harmless the City of Cadent iditol
incoitiequenc offt riling expenses which may in any way atom,against mid City
V inconu EARNE ofthcgraTANDfthis DW I 11_2-0
APPLICANT NDERSTANDS AND WILL COMPLY WITH ALL NON-POINT Issued by: Date b(
SOURCE RB LAT19NS.
/ f U1 1 f �Z -roofs
` Signatumm ApploanBnRe
Com
nur Dafc
HAZARDOUS MATERIALS DISCLOSURE Type of Roof
Will the applicant or future building occupant store or handle ha mdous material
as droned by the CuP,ninm Municipal Code,Chaptcr 9.12,and the Health and Safety
cane,semen xs532(a>7
❑rem Disler All roofs shall be inspected prior to any roofing material being Installed.
Will the applicant or future building occupant use Nuipmcm ordevius which If a roof is installed without first obtaining an inspection, 1 agree to remove
mit ha,ardous air contaminants in defined by the Bay Area Air Quality Management all new materials for inspection.
District?
❑Yes ON.
How mail the
rehavaNnusmaterialsreyoiremcnts under Chapter6.95of the Celifnr-
niaFF alth&Safcty Code,Sadt)m25N)5,25533and25534.1umm�tand thatifthe Wilding -
does nm currently have a tenant,that it is my responsibility w nod(y Be mcup.I Of the
gairements which must W met prior to immune of a certificate of Occupancy. Signature of Applicant Date
Owner or authrumd agent D:,
All roof coverings to be Class "B"or better