02120084 (2) CITY OF CUPERTINO ca n
BUILDING DIVISION
PERMIT 0CO4RA0T0RaINF0RMATI0N
BUILDING AUDRIiSs: PERMIT NO.
osis aZiLo08
OWNERS NAME: APPLICATION SUB DATE
Z ZUZO`J Z
ZONE: SANITARY O. CONTROL NO.
( v ) 73j - 79r7
I ARCHITICT/ENGINCER: BUILDING PERMIT INFO
I BLDG ELECT PLUMB MECH
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�00 umiNSEDCONTRACTOR'S DECLARATION
r u F I her by aflirm Nat I am IimnseJ under provisions of Chapter 9(commencing Job Description
l<a with Section 70000of Division Sof be Businessand Profeasinns CoJe,and my license is
in full force and effect Faia�ALIED
Licence Class Lic.N •
tozb Dam Contractor
iF=t:rcj ARCHITECTS DECLARATION YV APR 1 4 2003
a i I understand my plans shall be used as public records
KOyU
FLLOy Licensed Pnrlcxsiana
g OWNER-BUILDER DECLARATION BUILDING
y <f I hereby affirm that 1 am exempt from the Cnntnctnr's License Law for the
�a a O following reason.(Sation 7031.5,Business and Professions Cole:Any city for county
1 u$(v which requires a permit to construct,alter,improve,demolish,or repair any structure
IFZ< prior o its issuance,also requires the applicantfor such Permit o filea signed statement
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that he is licensed p...not to the previsionsofthe Comme, License Law(Chapter 9 Sq. Ft. Floor Area Valuation
ytuF$ (commencing with Section 710)of Division 3 of the Business and Professions Colc)or �0 0-10Nat he is exempt therefrom and the basis for the alleged exemption.Any violation of
Section 7031.5 by any applicantfor apermit sabjecu the applicant to or eivil penalty of APN Number Occupancy Type
not more than five hundred dollars($500). _ — O P Y YP
❑Luownerof Ne pmpeny,or my employees with waguutheir Bale compensation,
will do the work,and be s nactme is not intended oreffeed for sale(Sec.7044,Business
and Pomfessime,Code:The Commemn.License Law rices nut apply In an owner of Required Inspections
property who builds or improves thereon,and whodoessuch work himself or Nmugh his
own employees,provided that such impmvemenu are not intended or offered for sale.IL
however,the building or improvement is sold within one year of completion,the owner,
builder will have the burden of proving that he did not build or improve for purpose of
IL
.as Owner of the property.am exclusively contracting with licensed contractors in
MCI the project(See.7044,Business and Professions Cm1cU The Contractor's Li-
ceme Law does not apply to an owner of property who holds or improv thereon,and
who contracts for such projects with a comractor(s)licensed pursuant to Ne Caroector's
License Law.
1 am exempt under Sec. B&P C for this reason
Owner LUC' R ���k� 12
r WORKER'S PENSATIO Os' RATI
1 hereby affirm under penalty of perjury one of the following declarations:
1 have and will maintain a Certificate of Consent to self-hro m for Worker's Compete
sation,as provided for by Section 3700of the Labor Code,for the performance of the
work for which this permit is issued.
k1 have and will maintain Workers Compensation Insurance,as required by Section
3 of the Labor Code,for the performance of the work for which this permit is issued.
My Worker's Compensation Insurance carrier and Policy num her arc:
Carrier: Polity No.: _
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
obis motion need not he completed if the permit is foronc hundred dollars($10)
ser less)
1 certify that in 1 form of the work for which this permit is issued,I shall not
empinyanY pcmnn i rYmanncrsoa5 tf`M1c�/��3p subject to the Workers Cnmpensainn
Laws of California. a VyLt7LIL4
Appl'can LLV f a —4 I�`"."f Kt�
NOTI 0 APPLI ANT: L after making this Certificate of Exemptian,you should
bec. bjen m the Worker's Compensation provisions of the Labor Code,you must
OO forthwith comply with such provisions or this permloan.]l he,deemed revoked.
Z " CONSTRUCTION LENDING AGENCY
t: 7) I hereby affirm that there ixaconstruction lending agency lirthe performance of
ai �: the work for which this permit is issued(set.XKD.Civ.C.)
1 Q Lender's Name
Z Landers Address
U 0 I certify that 1 have read this application and sure that the above hibernation is
{t P correct.1 agree to comply with all city and county ordinances and sate laws relating to
0 building construction,and hereby anthoriw represcrottows of Nis city to enter upon the
W about-mentioned property for inspection purposes.
1 (We)agree m save,indemnify and keep harmless the City of Cupertino against
F' V) liabilitics,judgmenu,cosy and expenses which may in any way aecmc against said City
U 7 in consequence of the granting of this permit
•^r APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT Issued by: Date
SOUR REGULATION IZ COL
t Re-roofs
Si amM ofA, brain ommcmr Dam
HAZARDOUS MATERIALS DISCLOSURE Type of Roof
Will the applicant or future building tmcupam vnm or handle harvJuus material
as defined by the Ceperrho Municipal Cord,Chapter 9.12,and the Hca1th and Safety
code.Section z5slxarl ,/' a All roofs shall be inspected prior to any roofing material being installed.
❑Yea gN
Will the applicant or future building cecupant use equipment or Jcvices which If a roof is installed without first obtaining an inspection, I agree to remove
emit hic'mohus all ronutmimors es defined by Ne Bay Area Air Quality Munagcment all new materials for inspection.
District')
❑Yes
I have read the hauaNnustrow,als requirements under Chapmr&95 of Ne Califor-
hisHealth&Safety Cale,Sections 25575,25533 and 23534.Iunderaund that ifd¢building
does not currently have a tenant,that it is my respmsibility to nodly the Occupant o1'the
Mgtdm cnuwto _hmusttprom orismanccofaCcnificatcofOccup
anc O Signature of Applicant Date
net or awn rite agent Date I All roof coverings to be Class "B" or better