00090035 (2) CITY OF CUPERTINO
BUILDING DIVISION PERMIT CONTRACTOR.INFORMATION:
BUILDING ADDRESS: PERM I I r NO,
OWNER'S NAME: APPLICATION SUIT DA']H
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7
41 ZONE: SANITARY NO. CONTROL NO.VIINAR
0 Q ARCHITH LI!N)(NEER: ATI— - H1111.DING 1'Ii12M111T(NIU
_ Itl.l%'i ELECT 1'LUA1H A11iC11
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ce
has
I)Hj LICENSED cocensedI-RACTOR'Sp DECLAIiAT1oN Job Description
Iterchv 0)oI that am 0 he lie
rods prnv'Ixim,x of Chnmc,9(cmnmcneing
FmC� I,to f«(face; it Ell Divisiun3 of the Husinuss and l'ndcxsinns CPJe,nnJ myliren,ce
i.in full face; dfe,.
eg W a
Clms
Date Contracts'
or
a ARCHITECT'S DECLARATION
4 I understand my plan>shall be ued
,
as public na,rd>
TEMP POWER
e._p o I,iwnmA I'n,lcsxionnl
u S o that lam PtI11r,f f Df he ConaTI(lN
e hereby nffinn that 1 um cxcn,pt from Ihc Cnnlrncmr'x LiAnyc ty fur Ihc.
< following reason.(Section 7031.5.1lusinecs and Pr..in,iunx Com,Any city coli county
` which mMuims a pernin to amamet,alcor,impose,demolish,or repair any staraurc
ne per
prior to its issuance.also requires the applicant for such permit to hie a signed statement
,hal be is licensed pursuant o the pnemom,of contractor.License Law(Chapter 9 Sq. FL Floor Area Valuation
(commencing with Section 7000)of Division 3 of the nuainess and Profe,evo Code).
nr Lha he Is co, to thercfnnn and Ihc has,,lot the alleged caunt,dial.Any violwinn
f Station 70313 by any l,flh,nI for a Penni,sulJces the I'Theunt to a civil lendly
{fns,mm<Ihan live hundred dollar.($5(10). APN Number Occupancy Type
1.as owner ad the properly.nr lay employees wan,wager as their sole compensation,
will do the work,and the structure is not intended or offered for sale(Sec 704-1.
Business and Professions Cale:The Contractor's License Law'does not apply to an Required Inspections
w of propcny who holds o,Inq,me es thenam,and who does arch work himxlf
,,,though],is own entpmyces.pm,fed that such Impmvmnents life not intended or 35719031 . 00
offered fir ode,If huwes'cr,the building or impr v,r,Is wW within I.I. if -
nmplution,Our owner-builder will have the burden s,1Proving that he did not build or
improve lot pmpnse of
01.as meaer of the property.am eadushey contoaing with licensed comruc,nrao 103 — UFER .
continue,the project(See.7(94 Hminess and Prnfission,Cnde($The Contractors 304 — . ROUGH ELECTRICAL
License Law does not apply am an owner of posterity who builds or improves deal
and who commas for such projcens w'ub a eontracmr(v)licensed puauanl to the
Cman¢tnrx I.iccuw Law.
❑I am exctIv,�todccrr/{S_ec._ .l3&P C fnr do,rex son
Owner�'/J'vw.k� )4-e siO�' 11) 2_000 .
N'(IRKER 'COMI'IiNSAT1UN DECCLARATION
I hereby at firm under Penalty of perjury one of the Following declarations:
7 I ],Else and will mammal, n CI nlliente of ito self Proms, for W..ku. ,
Cum,no, n, us Provided Is, by Scetion 3700 of ,be Lahnr Cuda for the
perfnnnunm of Ile work lot which,mo permit is Issue'.
01 have and will maintain Worker's Compenwtion Insurance,as required by Swivel
3700 of the Love Code,for the performance of the work for which this permit is
cued,My Worker's Compenvmtion Insurance canter and Policy number are:
Carncc I'nley No.'.
CERT IFICXI ION()If EXEMPTION FROM WORKERS'
COMIlloNSATION INSURANCE
pLis section recall not le compleled if the permit is for one hundred dollar,
61i 4-r less.)
I cervi I that in the perrnrnnnme of the work lar which Ihis pnnnil is issued.I
shall nnI employ any Perre eny a as ,,ho,r P,wbjed m the Worker, .
Cnmpclm riun Laws of i Date
on
Applicant,
NOTICE TO APPLICANT:If,alcor making(his Cenilietle of Excmmp,inn,you should -
become subjttno,he Workers Compcnsatlon pnwisiona of the Labor Cold,you must
Q O forth aith comply with such provisions or this wrinit shall be deemed revoked.
r y CONS'I8UC1'I ON LENDI NO AG ENCY
I hereby ul'linn thre Ihere is n ennsmuctiuPi("olio,xgmmy or the P.,Ibrntunce
of be wok tin which,his peon,a issued(Secs 3097,Ci,C,)
L Q Lender's Nano
D 7 Lind,,'x Address
t.7 Q 1 Parody that 1 have read this applieaion and stem but the above information Is
correct.I agree to comply with all city and county ordinances and state laws relating
Q V to building construction.and hereby ardorite repre,ruilives of this city to enter upon
W tho ubnve.nenhnned properly I Inspm'um porpI've,
A. (We)agree nMm'n,indenmit'y and keep humnless the City Ell'Cupanot,aguir,
N l abilinea,judgments,coos and expenses which may in any way ace me against said
U Z City in cnnw4urece of the gaming of this permit. _
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT Issued by: Date
S�O�U/Rf� RP/�}j(LAT 5. L-ts 11,L0�0
S161maM1nc°I"App ,ntrac� -� _'( cote Re-roofs
EAZARIHMS MATERIALS DISCLOSURE s
Will me aptdmaecar mltue building occepam store ret handle heriarthsicral Type of Roof
m dehnal by Ihe Capemmu Municipal Code.Charter 11.12.and the Health and Safety
Code.Section❑Yes 25532(x)7 xNrr
All roofs shall be inspected prior to any roofing material being installed.
win he applicar,arI'uturebriliing,cerpuntuse equipmanordevices which If a roof is installed without first obtaining an inspection, I agree to remove
all hanaJous sir cunmmi rants:n deli Pied by Ila pay Arca As,Quality M.magement
Dunn"? all new materials for inspection. Applicant understands and will comply with
O Yea XN,, all non-point source regulations.
1 have rend the ha Uredi mamneH Muirmnents under Chapter 6.95 of the
California Health&Safety CiN,Sections 25505,25.533 and 25534 1 undcrxmnd that
i f the building does not currently have a tenant than it is my responsibil'Ply to notify the -
as,mpant of the requirements whiff n!g,P be tact poo,to i<auunce rf a Ceniheate of
Dian°,p,1 y'p (/�jl�� VK � J) �. Signature of Applicant Date
DY�,rranl�nriceuage r 1 I�tnu All roof coverings to be Class "Br'or better