04010084 (2) CITY OF CUPER•rINO
BUILDING DrvIs1oN PERMIT -CONT,RX -T .INFORMAT,ION
BUII.DINGADDRFSS: MISSION DEVELOPMENT CORP PERMITND04010084
BR'S NAME: - PERMITISUEDATE
{ONE: SANITARY NO. CONTROL NO.
ARCHITECT/ENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MEC"
o0o LICENSED CONTRACTOR'S DECLARATION JbDi Description
U 1 Wmby affirm that I em licensed under provisions of Chapter oescrp
9(commencing
ma wholly Section 70"W) Division7of the Ruaine dProfessinns Code,and my license is
'=y in full fn .antic L \\\\
ueen'No g REVISIONS (PIERS)
Dom Gr Tractor r N HOUSE ONLY-NO NEW PERMIT
!g ARCHITECT ARATION
Yw IundersumdmyPhnsshallWusc as PublicrecnNs ORIG PERMIT #031200174.
DyU
_0 Licensed Pm(cssiohad
Oat I am.UILDER DECLARATION
00 1 mason.
affirm that 11. caempe from he fissions o License Anyc Law or the
i00 whichfollowing teres a permitSectit 1 construct,
Business and professions de o li Code:Any tiny w canny
Z$ which requires a permit re cnres the eller,improve,h Permit t or e a air anylned metres
_Z< prionniu iensidI Incident
derequiree Novisdapp...if for sucf to Co Permit to Lu n.Unv aummem
ggthat he(commecingwJpununnlnuhcpmvivisionoftheBtmnessanProfeaw(Cop)orheraw 9 Sq.Ft. Floor Area Valuation
Y $ tat he is exempt
with Section and the
Divisionr of lac alleged
exempt on.Any
vi Cop)of
y Net he is exempt therefrom and Ne buffs for the dlogcd exemption.Any vinlmion of O
Section TOJl.5 by any applicant for a permit subjects the applicant to a civil penalty of APN Number Occupancy Type
not more than five hundred dollars(5500).
I,as owrmr of the propenYor mY cmPloyces wish wegeau Neinalc campenu0on.
will do the work,and the structure is not intended oronertd formic(Sec.1014,Business
and Proressiwu Code:Toa Conmcmr.License law does not apply to.a owmr or Required Inspections
property who builds or improves thereon,and who doessuch work himself ortbrough his
own employees.provided Nat such improvements art not intended oronertd For.ule.If.
however.Ne building or improvement is sold within one year of completion,the owner.
builder will ban the burden of proving Nan he did not Wild or improv for purpose of _
u1eJ.
❑1,as owner of the property,am exclusively contracting with licensed contractors to
construct the project(Sec.7044,Business and Professions Code:)The Convector's Lt.
teres Law does not apply to an owner of props ny who Wilde or improves Neuron,and
who contacts Our such projects with a contractors)licensed pursuant to the Contractor's
License law.
1 am exempt under Sec. .B&P C for Unit rtuan
I Date
WORKER'S COMPENSATION DECLARATION
I hereby affmn under penalty of perjury one of the following declarnions:
1 have and will maintain•Ccnificasa of Consent to stir-Insure for Workers Conoco.
sulon,u provided for by Section 37M of the labor Code.for be performance of the '
work for which this Permit is issued.
❑1 have and will maintain Worker's Compensation Insurance,ss required by Section
3700 of the labor Code.for dm p dormanm of the wwk for which this permit m laved.
Ca Work/omUrpyatLon� rtterPol'tcy NOand Policy
number am
C9E`RTIPICATErOFEEXEMPPTIONFROMWOKE L4'4L
COMPENSATION INSURANCE
(Tal.section need not W completed if the permit is for one hendmd dollars(g I(10)
nr kss)
I Unity Nat in the performance of the work for which this Permit Is hutted,1 shell not
employ any person in any manner so um become subject to the Workers Compensation ....
Lawn of California.Date
Applicant
NOTICE TO APPLICANT:Ir.after making this Cenifcam of Exemption,you should
become subject to Ne Worker's Compensation provisions of the Ia Wr Code,you mus
.,0 foMwith comply with such provisions or this Permit atoll he deemed revoked.
z E .r CONSTRUCTION LENDING AGENCY
.N. I hereby affirm that there its construction lending agency for the Performance of -
r7 Ne work for which this permit Is issued(Sac,3091,Civ,C.)
CQ. Lenders Name
z Lcnder's Addmse
U p 1 certify that I have read this application and state Nat Ne shove information is
IT. P correct.I agree to comply wit all city and county ordinances and auto laws mining to
0 building construction.and hereby auharine rcpreunutivea of this city to enter upon the
a above-mentioned pmpcny for insleadon purposes
(We)agree to urs,indemnify and keeP harmless the City of Cupertino Against
,F.r fg liabilides,judgmcnts.costs and capcoses which may in any way accrue Against mid City
tJ'z in consequence of the granting of this Permit.
_IAPPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NO POINT Issued by:9 Date
E REGULATIONS.
Re-roofs
gnemro of ApplicamuCommuctor HAZARDOUS MATERIALS DISCLOSURE Data Type of Roof
Will the applicant or(more building occupant stow or handle havudous material
u defined by the Cupertino Municipal Code,Chapter 9.12.and the Hcallh and Safety t,
c,Section 255J2(a)? All roofs shall be inspected prior to any roofing material being installed.
❑Yu ♦thio
Will rite applicant or future buildingocculwmtsc cyvipmenl or devices which If a roof is installed without first obtaining an inspection,I agree to remove
It havardnm air contaminants u defined by the Bay Arta Air Quality Management all new n)aterials for inspection.
C.
Cl Yes
I hevemad the ha Nous :Omis requirements under Chapter 6.95 of the Caliror.
nia HcalN&Safc{yC c duns25505,25533.d25534.1undcmundthatifthc Wilding '
docsnot cgnodtfy ho tenni,teat It is my res sihm ilitynndly the cupans or Ne
roquire adtswhien'mus OdLardfiB accnif¢amor ca cy. Signature of Applicant Date
i Cr'
prof au,h.H Cd agent m All roof coverings to be Class"B"or better