00010030 (3) MIMn "W ire
CITY OF CUPERTINO " n
BUILDING DIVISION PERMIT 'CQiVTRA@TpO, R INFbRMATIO r
BUILDING ADDRESS: PERMIT NO.
00010030
0 W NER'S NAME: PERMIT LSSUE DATE
ONE: SANITARY OL NO.
AR CHITECTIENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
, LICENSED CONTRACTOR'S DECLARATION "
0o Job Description
3 Z
�n F 1 bereby affirm Nal I am licensed under provisions of Chapter 9(commencing
" with Sttuon 7W)af Division Sof Om Busass aril professiOcu Code.and my license
'^�z
I.Li
full force mulattoes. �t
to I.i arm clan Lic.g FURNACE
vb� am—Contractor.
ARCHITECTS use DECLARATION
—t r understand my Plain shall be used as public aartls I
yULt
30G Licensed Pmf.asi...I V L
'' S OWNER-BUILDER DECLARATION
y I hereby abrin that 1 am exempt from the Contractors License Law for the
i00 following 2a.Wn(SCedUn 7031 S,Business and Pmfeaumbas Cade:Any oily or County
>e 2 which lariat s a Permit to convect.alter,improve,demolish,Or.,I,any strvcwm
pilar to its issuaaR.elm require lW applicant for such Permit to File a signed statemein
that he is licensed punuent to the provision of the Conlaacmr's LiceMc law(LTapmr9 Sq. FL Floor Area Valuation
(commencing with Section 7000)of Division 3 of lbe Business and Professions Code)or
..
that he is exempt therefrom and ft basis for IW alleged exemption.My violation of
Sector 7031.5 by my applicant for a permit ubjects the appllcanuo l Civil penalty of 33VNA14*er00 Occupancy Type
not more than five hundred dollars($510).
I,asmvner of Ne propuly,amy employes wlN wageaas toss role cmnpewtlon.
will d.thework.mcift.wcture isnotintendedoroRe¢d Wasda(Sec.706s,Businrss Required Inspections
end Pmfesaioos Code:The Conuac ,es License law docs not apply 0 an owner of q p
pfoanywhobuilds orimprovesbiropl andwhodaosuchwart mofficarIMugh his
ownemployes,provided NalsohimProvem within
t in:not intendedoroRemd faasleer,
build,, N.building aimprovementhmad withinane year of completion,Neowner-
builder will have Ne Wrdcn of proving this be did not Wild or Improv for puryore of
sale.).
I,as Owner of use property am eacleaively contracting with licensed contractors to
conssmcl the project(Sec.7W4,Business and Professions Cade:)The Communes Li.
ea.I.A.dors not apply as so owner of Property who Wilds or improv thcmon.and.
who contracts for such pmjccm with a contractor(s)licensed pursuant to the Contractors
License Law
lam exempt under Sec. ,B&PC for Nis moron
Owner Data
WORKER'S COMPENSATION DECLARATION
1 hereby affirm under penalty of perjury ane of IW following dexa mions:
1 bare and will maintain a Certifies.of Contin m self-inmro fa Wallace'Compen-
tian,as provided for by Sedan 37011 of the IJWr Code.for the Performa...of the
10317',W
rk for which this permit is issued.
I have and will maintain Workers Comperustion Iuurance,u required by Section
ofNe labor Code,far Ne pctformance of the work for which this permit is issued.
y Workers Compensation Insurance artier and Policy number em:
rtier: Policy Na.:
CERTIFICATE OF EXEMPTION FROM WORKERS COMPENSATION INSURANCE
(lTu section need not he completed If the Permit Is fa one hundred dollen(SIM)
per It.)
1 arlify Nat in We penromtmc.of Ne work for which this Permit is inucd.l shall not
employ any person in any meraefan as in become subject to Ne Workeri Compewtan
Laws of California.Data
Applicml
NOTICE TO APPLICANT:IL after making this Cer ibcam of Exemption.you should
become mhjcet to Ne WorkerW Le
Worker's Compensation provisions of tber Cade.you must
0,Z foMwidecomplywiNmchinowisiam or deice PcrmltshdIbcdccm.dmwked.
zO CONSTRUCTION LENDING AGENCY
[r 1 hcmbm yaffirthat these i,.eco tion lealft.gency or NC Pcrfurmsma or
a 9 the work for which this permit is issued(Sec.3097,Civ.C.)
VJ Q Lenders Name
=z Lender's Add.,
U I cenify that l baste read this application am sum Nu tho show information u
II.(—' amea I agra to comply with all city and county ordinances and sum laws miming to
V Wilding consu eetom.ane.Inde auNand eprexnmivaf this City menter
no agathe
abeve-mentioned proPeny for inspection pu poses.
(We)agme to new.indemnify and kap harmless Ne City accrue
id City
liebilites,judgmenn,costs and expenses which mryln any way accrve against said City
L)7, in consequence of the graining of this permit. Date
r APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT Issued by:
SOURCE REGULATIONS.
Re-roofs
Signature of Applican✓Contrantor Data
HAZARDOUS MATERIALS DISCLOSURE Type of Roof
Will the applicant or future building Occupant mom afhardlc hwardous material
u defined by the Cupenlba Municipal Code,Chapter 9.12.and the Health and Safely
Code.Schon 25533(x)7 All roofs shall be inspected prior to any roofing material being installed.
[DY. ON.
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 hazardous air contaminants w defined by Ibe Bay Ama Air Quality Management all new materials for inspection.
istrie"
O Y.s ONO
I have mad the haemes materials mquirom.nH under Chapter 6.95 of the Calif.,.
ria Hcal"Safety Cade,Sections 25505,15533 and 25534.1 undcnnand that if the Wilding
does nal currently ban it tenant that it a my.,maihilily in badly the oceapart of tha
requirements which must W met prier W Women ora certificate Of OC.uNncy Signature of Applicant Date
Owner or ainham<d aSam
Date All roof coverings to be Class "B" or better