05030154 (2) r
CITY OF CUPERTINO :w
BUILDING DIVISION PERMIT
N' '•I�.A, TC ��'11 ' ()R .'T�T(?1 :'.
BUILDING ADDRESS: PERMITNO.
05030154
712971 NEWSOM AVE
0 NER'S NAME: PERMIT ISSUE DATE
E; SANITARY ROL NO,
ARCHITBCT?ENGINEER; BUILDING PERMIT INFO
BO ELECr PLUMB MECH
O
�rOp LICENSED CONTRACTOR'S DECLARATION Job Description
(� 1 hereby affirm that l am licensed under provisions of Chapter 9(commencing
n� with Section 7000)of Division 3 of the Business and Professions Code,and my license is
I.full force and effect.
License Clue Lle.g ADD GARAGE 5281
Dam-Contractor
ARCHITECTS DECLARATION
I uneeratanJ my plena shall be used.s public records
o Licensed Professional
OWNER-BUILDER DECLARATION
I hereby sire that 1 t exempt from the f W,,Commute.License Law for the -1141
5 p O following moon.(Section 711315,BUeloess and are.de mm Cork:Any city Os coumy ��1444ssa
$ which requires•issuance,Alan on constuires a Bike Improv,hPermitt m repair ed statement
PHOT H fy
that he
itsensedpumm requireuW aisionsnt for such ofthe Contractor's
ice se signedw(Caremant
stat 6 (commescce withSecuan 7000)ofDivionenfththeBusaxes.nkenmlaw(Chodlcr9 Sq.Ft. Floor Area /f�S Valu tion
$ $ (cat he
xempth Section?and of Division n3 of theegeinexe andon,Anviladanions Code)of _
6u 33 11u1 he la exempt therefrom end the beau for Ne alleged evtmpnon.Any vlolatlon of
Section 7031.5 by any Applicant for a permluubjmts rhe applicant to a civil penalty of 3 79"YAJ9Ayer0 0 y Occupancy Type
not more than Five hundred dollars(1500).
❑I,u owner cribs prepeny,or my employee,with werges u their sole compensation,
will do the work,and the auucmm is not handed ar offered for tale(Sec.70th.Business
and Professions Code:The Conuadod Lkenm Low does not apply to an owner or Required Inspections
properly who bulletin,impmvea Hereon,end who doeuuch work himself or through his
.we employees,provided that meh Improvements am not thteand reoffered for Asia.If.
however,the building or Improvement is told within one year of completion,the owner.
builder will have the burden of proving that he did not build or improve for purpose of
sale.).
❑1,as owner of the property.am exclusively combeci ng with licensed contractors to
construct the pmjem(Sec.7044,Business and Professions Cade:)The countermen LI•
cense law does not apply in in owner of property who builds or Improves thereon.and,
who contracts for such projects with a contractor(s)licensed pursuant k the Contractor's
Lkenm Law.
❑l am exempt under Sec. ' ,B&P C for this reason
mer 5vo�asm1 Data
WORKERS COMPENSATION DECLARATION
I hereby affirm under Penally of perjury can of the following declensions:
❑l have and will maintain a Certificate of Consent to self-insumfor Worker's Compon-
sation,u provided for by Section 37M of the Labor Code,for the performance of the
work for which this permit is issued.
❑1 have and will maintain Worker's Compensation Insurance,an required by Section
37W of the Labor Code,for the performance of them work for which thio permit is issued.
My Workeeg Compensation Insurance canter and Policy number ere:
Centel: Policy No.:
CERTIFICATE OF EXEMPTION FROM WORKERS' '
COMPENSATION INSURANCE
(This section need not he completed If the permit is fortune hundred dollars($1001
or]cM.)
1 cenify that in the performance of the work for which this permit Is Immune.I shall not
employ any person in any menncr, sstoberometubjeclMhheWmkcri CmmpaMIion
Laws of California.Dam C
Appllcmt
NOTICE TO APPLI :IORN'�f,after MA14p this Certificate of Exemption,you should
become subject to the Worker',Componsalion provisions of the LAWr Cuts,you mug
.,O forthwith comply with such provisions m this permit shall W deems mwked.
CONSTRUCTION LENDING AGENCY
(.r I hereby affirm that Nese is a construction lending agency for the Performance of
�i> the work for which this permit Is issued(Sec.3097,Civ.C.)
W Q Lender's Name
]z Lcnder'a Address
V Q 1 cenify that I have rend this application and rete the be Above informallun ie
B,(~ correct.I agree to comply with all city no county oMnances and sum laws relating to
Q V building construction.and hereby Authorize representatives of this city to enter upon the
W ahnve-mentions property for Inspection purpML
(We)agree to sive.Indemnify and keep harmless the City of Cupertino against
„y rrAA liabilities,judgments.costs And expense,which may in any way mama against said City
In() APPLICANT UNDERSTANDSnce of the anting of IANhis�'WILL COMPLY WITH ALL NON-POINT Issued by: Date
SOURCE REGULATIO /!�,
Y7grfawm of nppOcenVCon�trmttoor �T . Data
— Re-roofs
HAZARDOUS MATERIALS DISCLOSURE Type of Roof
Will the applicant or fulmm building occupantarom mhandlc hrmrduus material
as defined by the Cupenino Municipal Code,Chapter 9.13,and the Health and Safety
Can,section 35532(a)7 All roofs shall be inspected prior to any roofing material being installed,
❑Yes []No 10
Will the applicant or future Wilding occupant use equipment or devices which If a roof is installed without first obtaining an inspection,I agree to remove
emit hazardous air contaminants as dented by the Bay Area Air Quality Management - all new materials for inspection.
District?
❑Yes ❑No
I haw mad the hamol material&requirements under Chapter 6.95 of the Califnr.
ria Health&Safety Cac,Sections 25505.35533 and 35534.1 undontand that if the Wilding
does not currently haw a tenant.that it is my responsibility in nmdly the Occupant of the
requ . in Mchmust nMIPriorInWUmroof2CcoifrcamofOccu cy. Signature of Applicant Date
ncruromhoruea asent All roof coverings to be Class "B"or better