03120030 (3) CITY OF CUPERTINOBUILDING DIVISION PERMIT '+ �, CTR ;TOM
BUILDING ADDRESS: PERMIT NO0 3 12 0 0 3 0
?71 �; RAN TTTATIJ RD
?R'S NAME: PERMIT ISSUE DATE
nEIKICHI
PHONE: SANITARY OL No.
ARCHITECUENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
p 0 0 0
xtO�p LICENSED CONTRACTOR'S DECLARATION Job Description
ZC 1 hemby affirm that 1 am Reamed under provisions or Chapter 9(commencing
<U with serum.igNparDivisine Saida,Bmixa mad Prolmahna Code.md my license Is 9�L� ren
j�Z- in full fame and erfa` DECK REPLACEMENT xFJ40
LimmcClass La.g
zI-. Dam Cmmwmr RETAINING WALLS awalf
yqt�' ARCHITECTS DECLARATION. 2004
sYt ii"�ed+ed a rsun Ian ell u public me G
yU
+0 icn dP s I A
OWNER-BUILDER DECLARATION 4Y
' 1 hereby affirm that I em exempt from the Conuam ,.NUAL�j[tlQG�Bor's License Law for the
Q fallowing (Section 7031.5,Bushromand Profe[Slonr Code:Any city arcomay
which requires a permit to construct,she,improve,demolish,or repair any sButmre
F�¢ prior m its issuance also requires the applicant for such Permit rile a Signed statement
that he is licensed pursuant to the previsions of the Contmc.ur'S License Law(Chapter 9 Sq.Ft. Floor Area VaWt3t10Do 00
$ (commencing with Section 7000)of Division 3 of the Bminesaoad Profcssinns Code)or y51L V
.. that M is exempt thmrrom and the basis for the alleged exemption.Any violation of
Section 7031.5 by any applicant for a Permit subjects the applicant o a civil penalty of APN Number Occupancy Type
not more Nan Ove hundred dollar,(5x110). 34217063 . 00
1,a owner of the property,or my employees with wages as their sole compensation,
will do the work and the,Wdam isnot intended o,.ff..d forsalc(Sec.IDM,Bminess Required Ins eChO �''3�
and Professions Cade:The Comment's License date Law daan,apply m e an owner of q p QJ
property who builds or improves theroon,and who does such work himself ar through his
own employees,provided that uch improvements am nolimmndel maRered rorsala If. 3 g) r)LoOA
Y
however,the building or improvement is sold within mm year ofcompletion,the owner- JUN N
builder will have the burden of proving Nat he did not Wild or improve for purpose of
tile.).
1,as owner of the property,am exclusively contracting with licensed contmcmrs an BUILDING
cpr spect the project(Sec.70".Business and Professions Cade:)The Comramer's U.
came law dose nal apply to an owner of property who builds or improves themon.and
whoconm,,for,uch prujecm with a coo.,o,,$)Ilansed pursuant to the C(Anuaaor's
Lleena Lew, -
I eon exempt under Sec. .B&P C far this myon '
¢r Data
WORKER'S COMPENSATION DECLARATION
I hereby affirm under penally of perjury ane of the following declarations:
❑I have and will maintain aCef ifiam of Consent to self-insure for Worker'SCompmo
sasion,m provided for by Section 3700 of the Labor Code,for the pc,famona of the
work for which this permit i,issued.
❑I have and will maintain Worker's Compensation Insurance,as required by Section
3700 of the labor Code,for the performance of the work for which this permit is issued.
My Warke's Compensation Insurance carrier and Policy number am: -
Carrier, Policy No.:
CERTIFICATE OF E)EMPGON FROM WORKERS'
COMPENSATION INSURANCE
(This union need MAIWcompleted Ethe Permit is i.e.hundred dollars(SmIB
nr leu)
1 certify Nat is the performance of the work for which this Permit is issued,I shall not
employ an ay in any manner an a to become subject M IWWorkeri Compensation
Laws of ta.Dem
APP.. I
NO TO APPLICANT:If.after making this Certificate or Exemption,you should
bo ,Object to the Workeks Compensation provisions of Ne Labor Code,you most
'
.J O for with comply with such previsions or this permit shall be deemed revoked.
z h CONSTRUCTION LENDING AGENCY
[—i Thereby 4MM that them is a concoction lending agency far the performance,of
C' r7 Ne work for which this permit is issued(Sec 309],Civ.C.)
W�Q Lender's Name
z Lender's Address
V Q I certify that I have mad this application and sum that the above information u
,y F correct.I agree to comply with all city and county ordinances and sum laws relating to
O V building construction.and hereby amhorice representatives of this city In cater upon the
L57 above-mentioned Property for inspection Purposes
0.t (We)agree to save,indemnify and keep harmless Ne City of Cupertino against r
r CA liabilities,judgmtnu.costs and cartoons which may in any way Seem=against mid City L�
U in consequence of the granting of this Permit.
�+ APPLICANT UNDE!5STkNDS AND WILL COMPLY WITH ALL NON-POINT Issued by: Date 1
SOURC R U �?
_a, f�s i Re-roofs
at rc ppl canVCon o Dau
HAZARDOUS MATERIALS DISCI URE Type of Roof
Will the applicant or future building occupant store arbandle hamrdous materiel
s defined by the Cupertino Municipal Code.Chapter 9.12,and the Health and Safely
>de,Sectionzss3z(a)7 -❑Yes XNa All roofs shall be inspected prior to any roofing material being installed.
Will the applicant or future Wilding occupant use equipment of devices which If a roof is installed without first obtaining an inspection,I agree to remove
emit ham,dnaa air conuminanu as mfired by the Bay Arca Air Quality Management all new materials for inspection.
Dis0ictT
❑Yea No
I have mad the nmssdaus materials mquimmcnts under Chapter 6.95 of the Califon-
ria Health&Safety Cade,Sections 25505,M533 and 25534.1 undro med that lithe building
docs not currently hart a tenan,that it is my remonsibilit I notify the"'upon.of tht
requirements which most W mel prior m issuance of a Ccnifcate acupancy, Signature of Applicant Date
ow"( zumormed ascot D,m All roof coverings to be Class"B" or better