04100161 (2) CITY OFCUPERTINO ., 7a.•, �'a7s�f7w. g " "
BUILDINGDIVISION .PERMIT " CO 'TRA�6RANFON''I
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BUILDINGADDRESS: - PERMIT NO.
04100161
BR
OWNER' AM PERMIT ISSUE DATE
E: SANITARY OL NO.
ARCHITEC(ENGINEER: - BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
.�00 LICENSED CONTRACTOR'S DECLARATION
1 hereby affirm that 1 am licensed under provisions of Chapter 9(commencing
- Job DesCrlptlOn,
with Scene.70fKBof Division 3oftic Business and Professions Code.and my licenxis
in(ullfmmmdcffmt.
z�z tone Class Loc.III " REVISION--IN HOUSE USE ONLY
Contractor aqq, Date ARCHItECPSDECLARATION NO NEW PERMIT ISSUED/ ORIG. 404031038
?W� I undemtanJ my plana shall W uwJ o punlic rccnms . ... ._ .. _ .
6
w0 Licensed Pm(csaionaL
OWNER-BUILDER DECLARATION
1 hereby moo affirm that Dem exempt from the Contractor'sLicense: Law for Incfoll _
i p O which re masa..(Saito]ID L5,B.alien. and improve,
demom Code:Any city or county -
$ which requtms a Permit re comhe altec,improve,deermit t fie a sir any mmclum -
s,�< thtnoitsisamnceururmquims theapplicantfor Connector.
Lim .LeeJ atatcmcm ,
O (mmmencingwdpucetion7 the)of Disionan(1WCOnusincu Ltm.w innsCopter9 Sq.Ft. Floor Area. ValuatiQJt,-15' .. -
Imt he Is exempt dominate
and the basis far of the a ed esa and..An,nns Cade)of *115
Nal he le exempt 1Wre(rom.and the bob for the alleged exemption Any violation of
Section 7031.5 by any applicant for a permit subjects the.pplican,ro a civil penny of APN Number Occu ane e
not mate than five hundred dollars($500). P y ZYP
❑1,at owner of the property,or my employees with wage as their role Compensation. 3753205
will do the work and the modern is not intended"offered for sale(See 70th.Bethune; ,
and Professions Coda:The CanuacwYs Wmresese Law does not apply he an Owner of Required Inspections
.aeny who Wiprovid reprosuch Improve who dmsauch work himwlfortlor We his
however.the building
ori improvement
sold withts in
ofcmpledo.for Well -
huilder ..Ne have
has sac improvement is halt within rote year of mproe for the purpose
of
'
builder will Woe Ne burden of proving that W did not Wild or improv for purpaw of
soled.
.u at of the property,am exclusively contracting with Iicemed contactors to
construct the project(Sec.7044,Business and Persimmon;Code:)The Comracmfs Li-
Coaw law arcs not apply to an mvner of property who Wilds or improves thereon,and
who contracts for such projects with a comncmr(a)licensed pursuant to tho Camnctor's
License law.-
❑temexy��44O%��SSSppp�t�t�underSw. Bk PC fort is moon
Ow F�& 711 —71 k Data 2(O
WORKER'S COMPENSATION DECLAR&T1�
I hereby affirm under penalty of perjury ams arrive following declarations:
have and will maintain a Ccnlfumeof Consent tolo
self- ure for WorkeYs Compen- -
action,o provided for by Section 3700 of Ne labor Code,for dm performance of the
work for which this permit is issued.
❑1 have and will maintain Workees Compensation Insurance.as required by Section
3700.1'0.Labor Cod.,for the imformrceof Ne work for which this pmol,is issued. -
MyWorkoesCompenudonlnwmnmcardcrvend Policynumbcram:
Canter. Policy No.:
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(Thiavection need nuthccompleum lftW permit is forone hundred dollars($100)
or leas.)
I certify that in the performance of the work for which this Permit is intend.I shall not
employ any Person in any manner an as Or becomesubject to the Worlcri Compensmlort
Laws of Califomia.Dam ,
Applicant
NOTICE TO APPLICANT.IL after making this Ccrtiricat of Exemption,you should
become subject to the Warlmfs Compensation previsions of thc labor Code,you mon
z rOM With comply with such provisions or this permit shall W deemed hawked.
z O CONSTRUCTION LENDING AGENCY
(--t IWmby affirm Nat drum is a construction lending agency for the performance of
7.> the work for which this permit is issued(Sm.3097,Civ.C.)
Wh A Lender's Name
]z Lender's Add.
U Q 1 certify that I have mad this application and stain that the above information is
Iia Curren.I agree to comply with all city and county ordinances and stare laws mlating to
0U Wilding construction.and hereby amourim representatives of this city to enter upon ate
W movomentioned property for inspection purposes.
gyt (We)agree to saw,indemnify and lamp harmless the City of Cuumino against
rq liabilities,judgment,costs and expenses which may In my way acme against saidCny
U Z in consequence of the granting of this Permit.
^� APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT Issued by: Date
SOURC GUL,}TI.O-NN
1� '(� Re-roofs
,§19 acre of ApplicarYContactor Data
HAZARDOUS MATERIALS DISCLOSURE/) Type of Roof
Will On applies.,or future building mcupantamrc or li k?Ndnur material
o defined by the Cupertino Municipal Code.Chapter 9.13.and the limits and Safety
Code,Section 35532(.)+ All roofs shall be inspected prior to any roofing material being installed.
❑Yes rNo
Will the applicant or future building occupant use cquipmenl or devices which If a roof is installed without first obtaining an inspection,I agree to remove
t hazardous air contaminants as defined by the Bay Area Air Quality Management all new materials for inspection.
earict7
❑Ym P.
Ihewmad Nc Waamms materimarcquiremcnts under Chapter5.95 of then Califon
his Hemltb k Safety Code,Sections 25505X533 and75534.1 undersmntl thatif ate Wilding
does not currently haw a tenenL that it is my mapeneihil0y,to notify the mcupant of the
mer.ternmis ich rota asu ceohcomficateof mapancy. Signature of Applicant Date
�d ° All roof coverings to be Class "B"or better
Owndrur authorized agent Dme