02110100 (2) CITY OF CUPERTINO "",i " � , ��.. .4
BUILDING DIVISION PERMIT CONTRACTOWINFORMATION `'
Un '4.4&l"4TERLING BLVD ABLE SEPTIC PERMITNO2110100
ox,19H`M ROWE 520 REED ST. APPLICAn2llp194Tp2002
Ak
OFONS (408) 377-9990 SANITARY NO CONTROL NO.
ARCHITECTIENGINECER BUILDING PI7RMIT INFO
BLDG ELECT PLUMB MI[CH
00 LICENSED CONTRACTOR'S DECLARATION bpp��SCr�r�
W.E I hereby alarm that I.m licensed ander mosinorsof Chapter 9(commencing REPAIR OF SEW
UN-71�'t
Z withScction7 XN)n(Divison3nf B . ncss and Pnofcs[inns Coale.and my liacnuis C /��
Z8=, in lullh W Itc' Z PII�IALE®
ya9 hiccn[G is Lie.N r
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F- I understand my plansshallshat li as public rAioods NOy 182001
XKKGyUr
FLL0 Licensed Ym(cssinnl
� i Oat lam exempt frImthe CnttION BUILDING $2500
1 hereby arm that 1 am exempt from the Contractors License law for the
or 00 followingrano..fSecmm7031.5.Business and Profession.,Codri Any city nr county
which requires a pctmil no construct,alter,improve,demolish.ter repair any struemre
prior to its issuance.also re4uires lheapplieam]for such permit o IIIc a signed natcmcm
=�< that he is licensed puroom to the provisions(if the contractors Llccow Law(Chapter 9 3S452t6F0dcID Valuation
Fo (commencing with Section 7000)of Division 3 of the Bminers and Professions Code)or
WNat he is exempt Orrefors and the basis for the alleged escroplom.Any violation of
Section 1031.5 by any applicant for apetmit subjects the applicant to a civil penalty of PNN Occupancy Type
not mom than five hundred dollars(s5w). 202 - UNDERFLOOR P UMBING
0 1,as owner of the property,or my employees with wages a their sone compenssnon.
will Jo the work.and Eric structure is not intended or offered for sale(Sec.701 Business p��'
and Professions Code:The Contrarieties License law docs not apply to an Owner of 507 - FINAL P/fvf �eC[IOIS
property who huildsor improves thereon,and who does such work himselfor through his
own employees,provided that such improvements am not intended oraBemd for sale.If,
however,the building or improvement is sold within one year of complelinn,the ow.cr-
builder ,will have the burden of proving that he did not build or imprme for purpose of
sale.).
0 1,as as,of the property,am exclusively contracting with licensed convectors to
construct the project(Sec.7(W4.Business and Professions Code:)The Contractors Li-
mes,law does not apply to an owner of progeny who builds or improves memon,and,
who contracts for such projects with a contraco r(s)licensed pursuant o the Contractor's
License Law.
O I am exempt under Sec. ,B&P C Ilir Nis reason
Owner Dam
41 WORKER'S COMPENSATION DECLARATION
1 hereby allirm under penalty of perjury one Of the following decfantions:
I have and will maimed.a Certificate of Consent to self asum for Worker's Compen-
sation,as provided for by Section 37001 of the Labor Code.for the performance of the
work for which this permit is issued.
0 1 have and will maintain Worker's Compensation Insurance,as required by Section
37)1 of the[,hot Code,for the pedormanm of the work for which this permit is issued.
M rk Compcnsaoon Insurance carrier and her m:
iet:.N IIA Poli m:AF7rC i't-y
CERTIFICATE OF EK F.MP'TION FROM WORKERS'
COMPENSATION INSURANCE
Cords section need not be complc¢d if da:Iximlt is for mm hundred dollars(511X)
in,les.)
1 certify that in the perfmmancc Of the work for which this permit is issued.I shall not
employ,any Person in any manner m a,m become subject to the WorkersCompensation
Laws of California.Dale
Applicant
NOTICE TO APPLICANT:11,alter making this Ccnificate of Exemption,you should
become subject 0o the Worker's Compensation provisions of the Labor Cocke you most
0 forthwith comply with such provisions or this permit shall he deemed revoked.
z O CONSTRUCTION LENDING AGENCY
t-. 14 I hereby Orion mal there is a construction lending agency lir the perimmance nl
L.Y. > the work our which this permit is is[ucd(Sec.3197,Civ.C)
Wh Q Lcnder's Namc /^R
J 1<ndckAddress
0 1 V
U. P 1 cenee oral I have read lhisty and coon and state that the shove ws rmaling Is
I. U correct.1 agree to comply and with all city and county ordinances and curt laws retailing e
V achowngcsmawctiomanJ hereby ambon prposesemativex of this city menter upm the
N.1 above-mem)ageinsaproperty for inspection
emnify an purposes.
(, fL
We)agree m cast,indemnify and keep harmless the y ac of Cupenst s against
N
liabilities,judgments.of the grassing of this expenses which may in any way acrncagainssaitl City
V z in consequence the RSTA06 of thisD WILL
�+ APPLICANT UNDERSTANDS AND WILL COMPLY WITH AL1.NON-POINT Issued by: Date
50 CE H LATIONS.
Re-roofs
ignalure of Appfican✓Conautm Date
I IAZARDOUS M ATERI ALS DISCLOSURE Type of Roof
Will the applicant or future our lding occupant store or handle moardous material
m defined by the Cupenino Municipal Code,Chapter 912,and the Ilcallh and Safely
coat,Section 255321a)7 All roofs shall be inspected prior to any roofing material being installed.
❑Ycs o
Will the applicamor fu m building uccupam usccyuipmcm lir Jcviccs which If a roof is installed without first obtaining an inspection,I agree to remove
emit hazardous air unmaminants as defied by the Bay Area Air Quality Management all new materials for inspection.
Disvict/
❑yes
1 have read the harardnusmaterialsoequiremcros under Clopmr 6.95 of the Cidoor-
nla Deaddo&Sul'cly Cala,Section,25505,25533 and 25534,1 understand mat if the building
does not currently have a tenant,that it is my responsibility to redly IM oaeup ns of the
mgaim bumostbcmmpdmteissunecu.Ceoficatel��'°an0y� Signature ofApplicanl Dale
;7;y,. All roof coverings to be Class "B"or better
Owner or oulhnrisd.gent are