04100036 (3)0C
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CITY OF CUPERTINO
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BUILDING DIVISION PERA'IIT
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BUILDING ADDRESS:
WELKIN INTERNATIONAL IND I
PFIMITNG04100036
OWNER'S NAME:
IT
PERMLSUEDATE
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SANITARY OL NO.
ARCHITECVENGINEER:
BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
LICENSED CONTRACTORS DECURA7ION
Job Description -
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1 hereby Affirm that 1 am licensed under previsions of Chapter 9 (mmmcncing
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with Sad ] )afDivlsios 3 aft Rud' an ofeuionacode,and my license la
Imm�ramm arcs '-• 10
License IJc.N
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REMODEL --MS., BATH/WINDOW REPLACEMENT/
O Con
ARCHITECrSDEC ATIO
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understood".
1 understood my plum ensu he used ss pis is mcnNs
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Licensed Professional - • '
OWNER -BUILDER DECLARATION
1 ncmby aal I em exempt from. the Contractors License Law far the
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following reason. (Section RD 1.5, Business tend Profession de: CaMy City or county
which mquims a Permit to construct,aiwr. improve, dcmelish, or repair any nroctuu
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prior 0 its issuance, also requires we applicant for orb Permit in Bk a signed mtomem
that he is licensed purhaenOo the proviamoi the Contractor's U.. LA. (Chapter 9
Sq. Ft. Floor Area
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(cammenewS with Section 7000).f Division 3.1' Ne Bminessaed Pmf seines Code) car
that he is exempt an mfmm and we basis for Ne alleged exemption. Any violation of
32SN91i(llgl1d000ccupancy
Type
Seeman 7031.5 by any applicant fora permit subjects dw applicant to a civil penalty of
Nat mart Nm RK heeded dalWs($500).
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❑ 1, m owner of dw pmpeuy, or my wplayms with Astro u Uwh sole eompemdon,
Required Inspections
will do dw workand Nearachme beat mtmded At offered fmsale(Sec. 7061, Bmirsms
And Pmfeceiom Code: The Contractor's License Law dors rot apply a an owner of
T' q p
enywhobuildsmimproves damsecnwork himselral NroWe Ms
hmsn,endwho
Own
however.ayvsildingtladthaumhimpmwmenu arcml inantled orolfemtl for We. If,-
buwew6 or improvement Is halt within One gess of completion. the owner -
ill howling
builder will have fire burden of proving mut he did nm timid or improv for purpose of
cele.).
❑ 1, As Owner of the pmpeny. am exclusively contracting with licensed centrsctms to
contract the project (Sec. 7014, Business and Professions Code:) The Contractor's U.
seem Law does not Apply loan owner ofpropeny who builds or improves thereon,and,
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who contracts forsuch projects with a comosctor(O licensed pursuant to du Caunctoes
License Law.
❑Ism exempt under sec. . B dk P C fm Nla moon
er Dsu
WORKER'S COMPENSATION DECLARATION
I hereby aflhm under penally of perjury am of dw following declantiom:
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haus endwillmeinuine CWriicemofComenuoalf-i u fwWuTkesComPen-n,
As provided for by Section 3700 ar the Labor Code. for the performance of the
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wort for which this permit is issued.
❑ 1 have and will maintain Warker'! Compensation Insurance. As mquimd by Section
3100 of the Labor Cade, for Ne peRnrmonce or the Auric for which Nu Permit is issued.
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My Workers Campenf Icer Immrana seder and licy nYmber Am:
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ee o Policy 6 4 7 d
CE FICAT'EOFEXEMPTIONFR 1WORKERS'
COMPENSATION INSURANCE
(TTissecllan rand not ho completed time pctmitis foronc hundred dollars ($1 00)
or Ica)
I minify the, In the performance of the work for which this permit is issued, I shall not
employ any person in any manner an As aa become subject to tM WorkerCompensation
Iowa of California. Dam
Applicant
NOTICE TO APPLICANT: IL after making this Certificate of Exemption, you should
become subject to the Workcea Compmumon provisions of Ow Labor Cade. you most
forthwith comply with such previsions or this permit shall he doomed ovulate.
LENDING AGENCY
warCONSTRUCTION
1 herby Ne Vert e constrec. direlc d apcmy for the perfurmenec of
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i 30 7. Cing
• Le work for which this permit ts issmd (gee. J091, CIV, C.)
jLendersNwe
Lender's Address
i I cerdfy that 1 have mad Nis spplimdon and taw Nat the show information Is
' coned. l agree to comply with all city and county ordinances and sure laws misting to
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building contumacious, and hereby su borim mprtsen Adws of this city to enter upon No
rm inspection
Above-AICIRIOACd properly purposes
(We) agree to UK. indemnify and keep hamruss tiw City of Cupertino Against
j liabilities, juduengmenucmuAnd expenses which may inmyway arneagtlnnmidCityin
APPLLIICANT UNDEof me RSTANDf AthisNord.
WILL COMPLY WITH ALL NON -POINT
Issued by: Date
S)RCE REGULATIONS
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Re -roofs
Type of Roof
n
gnetrtuafA piss HALA OUS MATERIALS DISCLOSURE D�
Will the applicant or rut we Wilding acupanuwu m lundle haaurdous material
,
as dcOned by the Cupertino Municipal Code. Chapter 9.11. and the Health and Safety
otic, Semon 25532m)?�Na
All roofs shall be inspected prior to any roofing material being installed. -
0y.
uyeel'u
If a roof is installed without first obtaining an inspection, I agree to remove
Will the applicant of future building o c equipment or kvmm wraith
it hmsrdaus air conuminanB ss dented by Ne Bay Ame Air Quality Management
all new materials for inspection.
istric
4Nu
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I have rtsd Ne WArdousmammalsmquimnwnu underCMp=6.95 oftheCaii(or-
nu Health&SarctyCede, Salons 33503.235]] and 33574.1 undersand Nuifde Wilding
Jam not currently haw a ant, Nat It u my mepomlbility m noury Nc occupant or the
rrytu ntswhicmm.st,iift, 'w wnceoraccnlncauofOC" cy.
Signa tureofApplicant Date
OC/
All roof coverings to be Class "B" or better
own Uratha mag m ate