05070091 (3) CITY OF CUPERTINO
BUILDING DIVISION PERMIT KONTRACTOR�IN�'ORMATION
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BUILDING ADDRESS: PERMIT NO0 5 0 0 0 9 1
OWNER'S NAME: PERMIT ISSUE DATE
E: SANITARY NO. CONTROL NO,
ARCHITECTIENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
I� t (� 0
ZOo LICENSED CONTRACTOR'S DECLARATION Job Description
u 1 hereby affirm Nat 1 am licensed under provisions of Chapter 9(commencing p
to wish Section 70M)of Division 3 of the Business and Prafcssimu Code.and my license is
^<d lo Bull to.and effect
;q= L;censoOss se,. BUILD SOLID WALL (NON-LOAD. BEARING)
-� Dam Comrsoor MOVE LIGHTS/RELOCATE HEAT/AC DUCTS
E~E ARCHITECTS DECLARATION
W I undcsvanJ my Plans shall he useJ as public moodsU.
RNA NAL F
GG Licensed Professional
5 OWNER-BUILDER DECLARATION
i�I I hereby affirm Out I am exempt from Ne Committees License Law for the )))
K O O following mason.(Sermon 7031.5.Business and Professlmu Cale:My city or county g / _
<$ which requires a Pettit to construct,idler.improve,demolish.m ncPon any mumu. /
°i<
priorto its issuance,also ro uires the applicant forsuch Permit to file a signed statement
Es0 Nat he is licensed purmant to the previsions of the Contrusuri License Law(Chapter 9 Sq.Ft. Floor Area Valua"000
z� (commencing with Section 7")of Division l of the Business it Professions Code)ser
y $ Nat he is eumpt Nerefmm um Ne bleu for the alleged esempuon.My violation of
Section 7031.5 by any applicant for a permit subjects Ne applicant to a civil penalty of APN Number
not mom Nan five hundred dollars($500). dWfType
pl,umwofNepmpmy,ormyemployceiwffi"g wNemmlecompemdon, 35920029 . 00
will do Ne work,and NcswMurt isnatimendcd Moffcred forsdc(Sec.7064,Busi has
and Professional Code:The Contractees Liana Law does not apply to an owner of Required Inspections
property who buiidsorimporms thereon,and who dmssuch work himself or through his
Own employees.provided Nat such improvements are not in.me.n croRrred for ole.if.
however.she Wilding or improvement is sold wirb;n one year c f mmphoon,Ne owmo-
builder will have the burden of proving Nat he did not Wild or improve for purpose of
salc.l.
❑1,as owner.(ft property,am odusively contracting with licensed conuacmrs N
construct the pmjem(Sec.7064.Bonimss and Prefessiou Code:)The,Contractors Li-
cc=law does net apply to on owner of property who Wilds or improves thereon,and
who contracts for such projects wit a conmacmr(s)licensed pursuance the Convectors
Ll,.
❑Ism em rood/QS ,B&P for Nis
Owner ✓1 �� fA-,- / Dau� L�
ORKER'S COMPENSATION DECLARATION
10 1 hereby arm under penalty of perjury one of the following declaationa: -
❑I have and will maintain a Certificate account o self-insure for WorkeesCoomn-
cation,u provided for by Section 37M of the Labor Code,for the performance of Ne
work for which this ponni,is issued.
❑I ham sed will mdnuin Workers Compemauon Inaumna,as mgdred by Section
1700 of Ne Labor Code.for the performance of the work for which this permit is issued.
My Warkees Compensation Im oro.canner end Policy mumber>R:
Cartier. Policy No.:
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
ObHsemion need not W o mpleted if the permit is forme hundred dollars(SIM)
or less)
I certify Out in Nc perfosmanc of Ne work for wM1;cM1 Nis permit is issued.I shall nm
employer)person in Myn becomes bfen�oN Wo rkerecompemauan
lava of Ca'car^ Da
APpliam o j
NOTICE Tb A- A'NV LIC after making this Certificate of Exemption,you should
become subject to Nc Worker's Composition provisions of Ne labor Cede,you mu51
.J.z foMwilh comply with such provisions or Nis Permit shall he Council muted.
Z O CONSTRUCTION LENDING AGENCY
[-� Ihereby al'Brm Out them,isa construction lending agency for the polormanec of
l.L Ne work for which Of.permit b issued(Sec.1097.Civ.C.)
Wh Q Lomdees Nunn
Z loathes Address
U0 I cenify Na 1 have mad this application and sale Nat the above information is
(L H correct.L since m comply with all city and county on inances and state laws misting in
C U Wilding construction.and hereby outhoone mpoesenu ms;of this city to onto upon Ne
above-mentioned property for Cxp ction Purposes.
H G (We)ague to save,indemnify and keep homeless the City of Cupcnino against
N
in
Of the
Of this pus oints. may in any way accow egaiw mid City ,
Uz in conuqucnee of Nc granting of this permit.
^ APPLICANT UNDERSTANDS AND ILL COMPLY WITH ALL NON-POINT Issued by: Date
SOU CEREG L ry _
_i/_. L Re-roofs
Sikoltufc O(AppiCanifiComnamer Dam
HAZARDOUS MATERIALS DISCLOSURE Type of Roof
Will the epplicam or future Wilding occupant Boom orhandic haosdous material
as dented by the Cupertino Municipal Code,Chapter 9.13.and the Health and Safety
CMC.Se zsslz(a)7
❑Yey. ON.
All roofs shall be inspected prior to any roofing material being installed.
Will the applicant or future building Occupant use equipment or devices which If a roof is installed without first obtaining an inspection,I agree to remove
.. it ha„mous air contaminants as Joined by the Bay Area Air Quality Management all new materials for inspection.
Dismict7
❑Yet ON.
1 have mad the Wnardous materials requirements under Chapter 6.95 of the Califor-
nisHealth&SdmyCedc.Seeuuu25505.25533 and 25514.1 usdcssund Nxt ifte Wilding
des not currently have a lent,Nat it u my uopemibility in rotary Me ecomen of M
not cnt.a n pnym��praCcoincaar fOccu�, Signature of Applicant Date
caner mmtbotlxd.Senl Date All roof coverings to be Class"B”or better