03100096 (2) CITY OF CUPERTINO �@, �'+s'
BUILDING DIVISION PEMI
RT �X0NTRAC QR_IaNFORMATION;
BUILDING ADDRESS: PERMIT NO.03100096 3100096
'R'S NAME: FERMG705URDATE
NE: SANITARY 3 CONTROL NO.
ARCHITECTIENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MPRH
0 0 0 0
�op LICENSED CONTRACT'OR'S DECLARATION
i 1 hereby Affirm but 1 am licensed under provisions of Chapter 9(commencing Job Description
.z1 with Scnicn]q%quf Division Sof NC Busincn and Prufcuiom Cotic.end myliccns is
d
in
brrgg i infullforce And effect.
LicenseClassC / DEMO
Dam on 836) /
ARCHITECTSDECLARATION CONTRACTOR: NAVICOr INC . (#24
/
r
tC Iunderstand myplansshall hcmcdasPublic racards 3 )
6
'LL
Licensed Professional
nt 5 Oat I A.tUILDER DECLARATION
C.Olosom '
N O
)M O I herchy el'Orm Then 1 1. aempe from the Conlns Coca:
:License law far the
❑O fallowingmann.(S)cuon 7031.5.Business and Improve,
de Professions Co d,:Anycity nr county
5$� which its isi a permit m em.A tha Alter,improve,Jem,.it 1.r repair any ewment
isopd.,in itscensed pals.mqn the the Applicant for suchrctoi's icessignedsummcnt
(commelicenmJpunuom7000)pavivisionofheBusinessndProfLAW lCh.ptor9 Sq. Ft. Floor Area Valuatog000.
2 Q (commencingwith Section 7000)Add
basis.n7 of he Anda.Any
nvilatedtic)of
Nn is eaemp0 thertfam and the basis for the alleged esempuon.Any violation of
neSection Man five
uryreddApplicant s(SSOMpermit subjects the eppicanttoacivil Penalty of 3M?3: yglger00 Occupancy Type
net mart Nan five hundad dollen(5500).
❑1,As owner of the amen,or my employees with wages AS their$ole compensation,
will Jo Ne work,and she structure Is not intended or offered for sale(Sec.7044,Business
and Professions Code:The Commemrs License Law docs not apply t0 an owner of Required Inspections
property who builds orimpmws Neraon,and who doeasuch work himself.,through his 704 - DEMO
Own employees,provided Out such improvements art not intended or offered for sale.If.
however,Ne building or improvement is sold within can year of completion.Ne ownrn
builder will ban Ne burden of paving that he did not build or improve for purpose of _
sale.).
1,es owner of Me property,em eaclmively trinomial with liccmed Caninot.n t. '
construct she project(Sec.7044,Business and Professions Coda:)The Contractor's Li.
CO.law does not Apply to an owner of property who builds or improves Maraud,and,
who coolness for such projects with a contnmor(s)licensed pursuant to the Contractor's
Lieease law.
[?I Am esempt under See .B$P C for this meson
WORKER'S COMPENSATION DE �ADTION1U
I herchy Time under penalty of perjury oro of she following declan0i.es:
I have and will maintain A Ccnif¢am of Contain no xIf-insure for Worker's C.N.-
sati.n,m provided for by Section 37M of Ne Labor Code,for Me performance of Ne
work far which this permit is issued.
iD 1 haw and will maintain Worker's Compensation Insurance,u mquimd by Section
POO of Ne labor Code,for the Performance of the work for which this permit is issued.
My Workees Compensation Insurance artier and Policy number art:
Cartier. Policy No.:
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
mdse scumn need not hecomplemd If the Permit is for one hundred dollars(SIM)
in kss.)
I certify Nat in the performance of the work for which this Permit is issued,I shall not
emPloyany peno�niqany man9ec�n as n. co c.0 A,,t.Ne Workcrs'Compcmadan
Lowe of GAhfOm `sea
Appiicaso ''fR� 1, '�
N��.ra•�y.a�'.0 A�L CANNT:IL after/,1,
glthis Cenifc le of Endufa on,you should
berpye subject to the Worker's Compensation provisions of Ne labor Cotic,you must
�p fo rah comply with such provisions or this permit be deemed dwked.
ti� CONSTRUCTION LENDING AGENCY
1 hereby a(f rm Nat there iso construction lending agency or the Berfurmance of
li M Me work for which this perm it is Issued(Sec.309],Civ.C.)
i7 0 Lcnder'a Nam. '
Z Lender's AdNcss
;J O I certify Nu 1 haw read this application no sure that Ne Above information is
f-' correct.l agree to comply with all city and county Ordinances and state laws relating to
�U building coaswction,and hereby AMOmim OtPamntatiwa of this City to enter upon Ne
[21 above-mentioned property for inspection purposes.
r G (We)Agree to save,indemnify and keep harmless the City of Cupertino egainn
h Ilabllities,judgmenu.costs and aspmacs which may In any way see=against mid City ��
..)Z in consequence of Me granting of this Permit.
" APPLICANT UNDER ANDS AND WILL COMPLY WITH ALL NONPOINT Issued by: Date �7/,27
SOURCE GULATION . ^/
�I ((1 ) q Re-roofs
marc of ApPlicandmn
Co ' Data
HAZARDOUS MATERIALS DISCLOSURE Type of Roof
Will the applicant.,forum building Occupant stem or handle Nostrums,material
u dented by Ne Cimarron.Municipal Code.Chapter 9.13.and the Health and Safety
.Sc)tion 2ss72(,I] � All roofs shall be inspected prior to any roofing material being installed.
❑res IYI No -
Willtheepplicamorfmurebuilding occupant use equipment or devices which If a roof is installed without first obtaining an inspection,I agree to remove
It ham,dous Air conmminanis m td:Oncd by Ne Bay Arca Air Quality MAnag)me01 all new materials for inspection.
oriel?
❑Yes MINA
I have mail the h ranks materials requiamcnu under Chapter 6,95 of the Califor.
niu Health Safety Code,Sccuun 25505,25533 and 8574.1 untknund Nan if IN,building
does not otemolly hew A¢naps that it is my respoaNiliny to runty the,occupant of Ne
raqui;m whic0 usl met pooruiss ccofit Certificate ofUcu � Signature 0 f Applicant Date
wncr or au hma.d.,cut pan) All roof coverings to be Class "B"or better /