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04030173 (2)•CITY OF CUPERTINO INkaU'RNiA'I01„' BUILDING DIVISION PERMIT(J,11td� BuaDING ADDRESS: BENCHMARK DESIGN PERMIT ND. 04030173 HER'S NAME: MILLS TTqF.()p0RE 1382 MARIA WA34 PERMIT ISSUE DATE ..ONE: SANITARY ifP OL NO. ARCHITEC (ENGINEER: BUILDING PERMIT INFO BLDG ELECT PLUMB MECH LICENSED CONTRACTOR'S DECLARATION Job Description 1 hereby affirm that 1 am licensed under prevision of Chapter 9 (commencing with Section ,.f Division 3 of the Business straltFilufachous Code, and my liciums,I �•"•'•^^�--�. _, in ren lnrce ryidffreQ�_' LossZ" �° EVISION' -IN HOUSE USE ONLY WccnxC Dai _cmtwcn NO �RMIT ISSUED/ORIG. #04020099 W ARCHITECT'S DECL�S TION 1 understand my plans shall be used u pub c mcoNs ✓�, Licensed Professional OWNER-BUILDER DECLARATION 1 hereby .(Sere 1 exempt from the Contractor's Law for the lV : Any c IIDL5, Business Prolusions Code: Any city in county following meson. on 1. r, - itad a Permit t cnnswcL aheG Wprow, repair any swcture which Permit which _ its issuance, requires h Permit t fl Cn( applicant of forsuch panes License Law( sume(Chaplet pllor e1 i 31Ynsed heialieenxdw�ammtheproWaipnnrmeconitaamrauannxl.w(chapmr9 rsuanththe Sq. Ft. Floor Area Valuation $0 that p pro (emenoneft with Sutitat7WO)of Division 3 of the B.m. and Profession. Code) or 1 . dist be Is uempt thorefrom and the basis for the alleged exampnon. Any violation of APN Number Occupancy Type Semon 7031.5 by any applicant for a permit subjects Om applicant in a civil Penalty of not mare than Rw hundred dellen ($500). 32649012.00 0 1, as owner of the property, or my employees with wages a their sole compensation, Required Inspections will the fon an B Comi[nor's Licdedmoaertd t apply in mer or ons Cade: The Conmctor'a law does not apply lf an owner of and pmrsub ou Co he 9 P wh ndwhot datasuchwork his pro pertywhobuildsorire property oraelfedthrougM1 that such Nrertd for awn employees, provided that inch Improvements are m Ironer, is hath within one year or completion, Ne ownco however. Ne building or an you ' den of rmant builder will have the burden of protan{ Net he did not Wild or Improve ran purpose of u1eJ. ❑ 1, as owner of the lumpily, ily, em exclusively contracting with licensed convectors to convect Ne project (Sec. ]OM, anobac a and Profusions Code:) The Connector's Lt- came law docs not apply to an owner of property who Wilds or improves flu mon, and who common; for such projects with acantracmr(s) licensed pursuant to the Contractors License Law. ❑ I am attempt under Seo. ,B&PC for this main liar Date WORKER'S COMPENSATION DECLARATION I hereby afflIm under penalty of perjury one of the fallowing decelerations: 0 Thaw and will maintain a CartiBum of Consent to self-insure for Workers Compton. nation. as provided for by Section 3700 of the labor Code, for the performance of the work for which this Permit is issued. 0 I haw and will maintain Worker's Compensation Insurance. as required by Section 3700 of the Inbar Cade. far the Performance of she work for which use Permit Is issued. My worker[ Compensation Insurance carrier and Policy number are: Cartier. Policy No.: CERTIFICATE OF EKEMPDON FROM WORKERS' COMPENSATION INSURANCE (Thlssecdon nwd not he completed if the Permit Is formic hundred dalim n W) or loss) I coolly deal in the Perrornmcm a the work far which this Permits issued. I shall not employ any person in any in x mmLecamr}pbjcl rZMorkeri Compen[etlon Laws Of Celifand T^IT _ g Applicant NOTICE TO A71PLICANT54LIefter making this Ccnificam of Exemp ren, you should Wcome subject in the worker's Compensation provisions of the Labor Code, you must forthwith comply with such provisions or this Permit shall be deemed revoked. CONSTRUCTION LENDING AGENCY I handby den theme is a construction lending agency rn Ne performance of which d(Sce30 menLe work for which thio permit is issued (Sec. 31197. Civ. CJ Lender's Name LcnderY Address ' I certify that I ban read this application and [um that the above information is Comem. l agree to comply with all city and county ordinances and stain lawn relating in building convection, and hereby anthadra representatives of this city to enter upon Nc above-mentioned for inspection purposes. property a City Cupertino 4 (We) agree to taw. indemnify and keep humleas the of against 7 liabilities, judgments. cam and expenses which may in my way seems against said City in consequence of th Ong of this permit. APPLICANT U RSTANDS ANO WILL CO PLY WITH ALL N0 INT SOUR ATIONS. / Issued by: Date Re-roofs Type of Roof Signature ol'AplilualinuContractor f Dow HAZARDOUS MATERIALS DISCLOSURE Will the applicant or future building occupant store or handle huardous material as defined by the Cupertino Municipal Code, Chapter 9. 12, and the Health and Safety No. Section 25532(a)7 CYet 'lftt.'u All roofs shall be inspected prior to any roofing material being installed. If a roof is installed without first obtaining an inspection, I agree to remove Will the applicant or future building Occupant tax equipment or devices which emit hannumm air contaminants as defined by the Bay Area Air Quality Management all new materials for inspection. District? y 0 Yes Nu /News I haw raaddeehe materials rcyvircmcnuunde,Chapter 6.95 ofuc Cilifar. niaficahh&Safety ,Section 25505.25533 and 25534.1 umbmwad thatifft building - Joes nal carte ave a unenL Oat it is my mammal sty m notify the Occupant of the m uiremc i muubcmetpriortu CcNtic mor Occup y. Signature of Applicant Date C I d All roof coverings to be Class "B" or better Ownararautho . gent