01020123 (2) CITY OF CUPERTINO
BUILDING DIVISION PERMIT CONTRACTOR INFORMATION:
NUILDINGA nRCSS PERMIT NO.
O 2 0Z
OWNER'S NAME: APPLICAT[ON SUN DATE
I'1g)NG: F SAN]FARY NO. CON'I'SOL NO.
BUILDING PEIt MIT INFO
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p-,.o AMCHI'fliC'I/IiN(ilNlil M: BLIH'i GLECI' PiUSIB MECH
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z5vg IWrobraHuCuinslli,,;lien.cJunJcN'Pi,lrcinARici�p"eremr,n,lneneing Job Description
F=CLL with Section'ItgpiDivision 3ofthc Nusine—ad Professions Cdaandmy license
a mm Is in roll Ibrce and cl'I'cct.
a' a Li ccnsc clans Lic.N TC
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Use DECLARATION I J�JBL
t• O nRCI{ITECT'SDECLAMATION t
g I understand illy pLca"Itall be ailed us Public neords a, /
w d o O Licensed Promiu fowl
a. OWNER BUILDER DECLARATION
u�= I hereby:dhmt Ihat I n empt from the Contract or'v Licenw Law for the
t < lidlnwing rmsnn.Perot,,
a)u L.I. ..1her. and wefde n l Crete:Anyemu airy ,county `
ad 2 O whirM1 reyu:rcs a peat(In eonslmw4 alcor,improve,h pernit t file
repair any.cactus
8. prior mils isswncc,also ayuimxthe applicant for such permit mfileasiennl.utemcnt
-
Ihatheivlicensed pursuant to the pmviaon%of the contractors Liceme hw(Chapter 9 S9" Ft. FI or Area Valuation
commencing with Saloon 7000)of Division 3 or Ill,Itusincesad nProfession,code)
I"(be,he is cxvar,Ihcnefirl and the hassle lar the:dleged exemption.Any violation
of Smfinn 7071.5 by any applicant for a rental subjects the applicanl to a civil Penalty
of not more than five hundred doHaa(5500). APN Number Occupancy Type
Cl 1.as owner at the property.or my emph,res with wages as their sole c„mpcnaation. IDa�..eL
will Jo the work,and the smucmm is not intended or offered for sale(Sec.70f4.
Business and Professions Code:Ile Contractor's License Law dors not apply to an Required Inspections
cancer of property Whit hoilds or improves thereon,and who does such work hinivell
,r Ihongh bis own e:nployecs.proluild thal inchitm,nacats l un Intended o
ofYamd[of sale.IL however.the building or impowcmm
eis sold within one year of
nnplecion.the owner—hiker will have the burden of proving that he did nm Wild or
impmvc for pmpnse of salt), -
❑1,as m ,r of t •pmpeny,out xclusivdY a,mracting with licensed contractors m
construct the pr Sm.7(W.Business acid Professions Cash:)The Contactor'.
License 1':w Jr all a Is v,an owner of p openy who builds or impmm,tbemon.
and who onl s Ibr eb pnjeew w' a n trach s,)licenced pursuant to the
Contract
❑Izmew land .B K P C for this reason
lei
WOIIKEWS COMP. SAIIONIII!CLAR LION
I herby norm under Pen of Perjury one of the following declarations:
❑ I have and will maintain a Ccnifcum of Clawal 1.edl insure linW alon.s
Compensation, as provided for by Section 3700 of the Labor Code, for the
laerfonnmme of the work for which chis permit is iiia J.
❑I have and old inuinmin Worker's Coml"n,calic howl—aa.m required by Section
37M of the IaWr Calc,for the pctlbnnanm of the walk lo,xhill Ibis peril is
sued.My Worker's Compensation Insurance carrier and Policy number arc:
Carrinc PolicyNu.:
CERI IPICAI'ION OI'F"XENIPIION 1920M WORKERS'
CONIPENSAIION INSURANCE
(ode cation need not he oa,Iufad if Iba permit is Ibr one handled doll—
(gl0K0 nr Its)
I many that in the safamunm of the work for which this permit is issued.1 -
,hall not cnapiny any person in tray I yr a,as u:heco:ne suhjcm h,the Wo ka”
Compensation Luws of California.Dam
Applicant
NOUCE'10 APPLICANT:IL after making this Cenificum of Exemption.you should
nwoneunjca w the W..kur'n Cour,cosadon Pnwisions of the I.aMn CnJr.you must
Q Qm Ibnhwith comply with such pnwldons or Ibis permit shall N Acemed revokal.
z2
F ^ CONSTRUCTION LENDING AGENCY
ai 7 I only affirm that here is a conoradion lending agency for the verforance
of lac work fior which lhls knob is isxnal lSm.7097.Civ.C) .
6. Q Leader's Name
7 Z Lender's Address
(..1 Q Irenil'ytbul l hava read this n,lianion; In,an,lud the weave In lotion Ilx
Rn t..: cosec ce I rn:nply with n1I city and county nrdinanaes and slam law,relating
Q V h,but Jing co a action.and hereby anchorvu¢praunwtive,oOhis city to enter upon
the an ve J pm.in 1Int inspection purpn¢s. %1
F •) slim . "Kilda lis and wap I only innu,cityofcall.naagainst
'n City in dgmcn ,Casts xM cxpca h may in anY way antras ugaine wid
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City in c nen of IM1c gaming his
w 1.
^ APVLit VI ' lERSTANI LCOMPLYwirnIALLSION.POINT
I E r N' Issued bye -:�P— /�/ki7Jf��['eer Date O/
gm I. Applicant at or [)ate Re-roofs
HAZARDOUS NIX] iRIALS DISCLOSURE
WI11 the applimin or Insure building occupant tom or h:tndle hwnnlous mamrlal Type Of Roof
It,Jdined by Ibu Cal:acra Municipal C .Chapter 9.12,.,,it the Heal,and Safety
Calc,Section 25532(a)1 -
OYes All roofs shall be inspected prior to any roofing material being installed.
Will meappIcl cut ordevim,which If rc f is installed without first obtaining an inspection, I agree to remove
mit hanchka,air conmminanas m def incl by the Hoy Arcu Air Quality Management
uietdcr all e Is for inspection. Applicant understands and will comply with
all n oint s u regulati us.
1 hu c lir tin mnlous la iula rcyuircmcnts under Chapter 6.95 of the
Ca domia cal a ffi Safe Cale,Sections 25505,25533 and 25534.I understand that
if, chit mga not mmlyhavcamna Ihat mymsponsihill,u,anufythe
t'll ,f ten uhi
i ems wch I owl ,r to iss..arm at'a Cl nificahe A
°c nP y' / Signature of Applicant Date
orae All roof coverings to be Class `B" or better
OFFICE