05010127 (2) CITY OF CUPERTINO �s �s,� •` ` �' = �TI9
-'�
BUILDING DIVISION PERMIT �UNTRA.C�TQRI URMA
9ka^�b4Y"d;`S'd•`.. _,ktaa:..v�E�+"'�'� bx� r^�5 -
BUILDINGADDRESS: SMI CONSTRUCTION INC PERMITNOOSO10127
OWNER'S NAME: PERMIT ISSUE DATE
ONE: SANITARY C NTROL NO.
HIIEC(ENGINEER: BUILDING PERMIT INFO
BIRO ELECT PWMB MECH
ep o 0
LI00 LICENSED CONTRACTORS DECLARATION Job Description
1 hereby OHM Nal 1 ast Named under pnowdoes of Chapter 9(commencing
M Section 7000 of DiAslon 3 o the Business and Professions Code,and my license is
w'
j In full fma and effect.
L�- Lit. uc.g TI-EXTERIOR WINDOWS/CEILING LIGHTS
Dock ARCHITEC %DECr A ELECTRICAL/RESTROOM UPGRADE
-ULL my ph.Mall bo used as public records
C Licensed Professimul
OWNER-BUILDER DECLARATION
iV 1 borchy aM m that 1 sm exempt from the Contractor's License law for the
i Q o following mason.(Sudan 703 Id,Business and Prefestion Code:Any city or county
UE! which requires a permit to construct,alar,improve,demolish,m repair any mucture
F,�y prior k its issuance.also mquires theapplicant forsnch permit to Ole a signed statement
that he is licensed pursuant o t e prevision of the Comennori License Law(Chopw9 Sq. Ft. Floor Area Valu1 ql 1500
a (commencing with Section 700M of Division 3 of the Business and Profession Code)or 4
that he Is exempt De,mfmm and the bast&for gas alleged c¢mpdon,Any violation of
Section 7031.3 by my applicant for a permit objects the applicant to a civil penalty of APN Number Occupancy
am mom Nm Eve hundred doRsar(M), p y Type
❑L as owner or the property.or my employees with wages As their sole compensation, 3162.3027 . 00 '
will do the work.and Ne stmctum is not NkMCd a offered rat Me IS".7044.Business Required Inspections
and Professions Code:The Crumelor'&License Law data not apply u an owner of q p
property who buildsorimpraves thereon,and whodoesauh wort himselfurthmugh his
Own employees,prevailed that such improvements as not Intended"offered forsak.It.
however.Nes.Ove
orimprovement issaidwithin one Year of[am "I .Neowner-
builder will have Ne,dvden of proving that he did rot build or Improve(or purmre of
use.).
❑1.As owner of the property.am esclusively contracting with licensed contratnen to
conswcl Ne pmjca(Sec.7W,Business and Profession&Cade:)The Comracur's LI- �aI
cove Law dais not apply a an owner of property who builds ro improv thereat.and
who contracts Law da forsuch pmX<u with onuamorty who
sedWil pursvmmthe Cemen.ors
and
License Lew.
❑Iamesemptunder See .Bd PCfmthiswon
Owner Data
WORKERS COMPENSATION DECUBATION
I hereby&Klan under penalty of perjury one of Ne following declarstia s:
have end will maintain aceNOcak orconscm in self-ivum for Worker's Co amn.
— -- ,an provided for by Section 3700 of the Labor Cade.for the performance of the
for which this permit is how.
�1 ban and will maintain Workeei Compensation Insurance,v required by Section
3700 of the labor Code,for era performance of the work for which Nu permit is issued.
My Worker'_ T� "t Ipensauosan�o0cy mumbo_ ,re:
Carrie. POI' FROM
R FIC TE OF PITON FROM ORKERS
COMPENSATION INSURANCE
Clseuun need not W completed If the permit is furan hundred dollars($100)
or leu.) � •
I comfy that In the performance of the work for which this permit is issued.I shall not
employ any person in any manner an v an become subject to the Workers'Campcmadan
Laws of California.Dau
Applicant
NOTICE TO APPLICANT:It,Apar making this Certificate of Esemption,you should
become subject to the Worker's Compensation provisions of the Labor Code,you must
.JO f.muith comply with such provision or this permit shall be cleared!mvmked.
.z CONSIRUCrION LENDING AGENCY
(~ I for which ren Natthem kaco (Sce.3 leading
Agency
for Ne perfamue,e of
94 rte., the work for which Nis pemtit is iatned(Sec.J(191,Civ.CJ
aQ Lender's Name
Z)Z Lenders Address
U0 I cardly that 1 have read this application and sues that the above information k
!. corma l agree In comply with all city and county aninanca and auu laws mIWngu
0 building convection.and hereby auNarim mpmmmatives of this city to enter upon the _
W above-mentioned property for Inspection purposes.
(We)agree in ave,i nify ad seep harmless tiro City of Cupertino against
a.a In Ilabilidu,jWFTS4�n�
de hath y in any way ateme agalntsaid City
t.)7 In eotvequg o u pe Ib
G APPLICADS A COMPLY WITH ALL ON OINf Issued by: Date
Re-roofs
Signature of Appli Y0mun or, ase
HAZARDOUS MATERIALS DISCLOSUR Type of Roof
Will de,applicant or future building occupanumm or ha k harudov material
u darned by the Cupertino Municipal Code.Chapter 9.13,and the Health and Safety
ewe,sDYti z6s3:(an �Bo All roofs shall be inspected prior to any roofing material being installed.
WIII the applicant or furore building occupant we equipment or devices which If a roof is installed without first obtaining an inspection,I agree.to remove
It hanNov it contaminants at defined by de,Bay Arta Air Quality Management all Iley,rt)ateriafs for inspection,
❑Yes ICN.
I havemwthe hassNous mamri q imn .m1MCImpw6.95 ofd.Calif..
nu HcslN&SafnyCade,Sauon25 .2533 me25 .I uwcratutd that true,building
Jars not curcntly ha?' Akita my ms ns IN dfy the OMMOnl of Na
rsqulremenu whit R be me arwinuue,c . ase or occupancy. Signature of Applicant Date
Owner mautharimd c / Dau All roof coverings to be Class nBa or better