03120035 (2) CITY OF CUPERTINO °* '✓ ` ' 'l '� " ' "
BUILDING DIVISION PERMIT �CON°I'==RAC`TORINk,d' RMATION _
BUILDING ADDRESS: PERMIT N0.
AN KY CONSTRUCTION CO 03120035
NynAig EWS NAME: PERMIT ISSUE DATE
G
ONE: SANITARY OL N0.
ARCHITECT/ENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MEC"
0 0 0 0
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LICENSED CONTRACTOR'S DECLARATION 70b DDSCTI h p
1ion7 )of that 1amI Mae Hiioul underProvisions ofChapter oulk. 9(m It...
P
mcmint
M Sectio]OIID)of Dividers 3Of the luaincar and Profcsions Cade,and my licanse is
a full forte and effml.
Limas Class Lieg ADD 772 SQ. FT.
°ate Contractor AUG 3 2004
ARCHITECTS DECLARATION
1 understand my plans shall be used as public recnms
;o L'v:cnsed Pmfrssionel _ BUILDI U
y OWNER-BUILDER DECORATION
i f 1 hereby affirm Met I am exempt Tom the Como cors License Law far the
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following reason.(Section 7031.5.Business and Freboa na Code:Any city or county
+�$ which requires a Permit to construct.eller,improve,demolish,or repair my struclum
r Prior m its issuance.alto requires the applicant for such permil to file a signed statement
Nn he is licensed pursuantmthe pmm
visioofMeContractor.Limp.U.(Chapter9 Sq.Ft.Floor Area Valu hon
!�O (commencing with SWion7OD)of Divh;hm3 ofdte Buinusand Profasiom Cock)m
.. Net he u eampt themfmm tod the basis for Ne alleged assumption.Any violation of
&man 7031.5 by any applicant for a Permit subjects the applicant to a civil penalty or 3�3I'�JQyg3�er0 0 Occupancy Type
not more Nan five hundred dollars(5500).
❑I,u owner of the property,m my employees with wages u their sold compensation,
will do Ne work and the sweute is not intended or offered for sale(Sec.7066.Business
and Pmfessiou Code The Committees License Law dos at apply in an Owner of Required Inspections
property who bulldsortmp.thumn,andwho doasuchwmk himselfor through his
own employees,pmvlded dui such Improvements are not intended malRred for sak.If.
however,Ne building or improvement is sold within one year of completion.Ne owner.
Witter will have tie home.Of moving that he did Out build or improve far purpose of
sale.))..
Wf as Owner of the property.am exclusively contracting with licensed commons to
Carol=the project(Sec.7064.Business and Profusions Code:)The Chairamri Li.
cense Law does not apply to an owner of property who builds or Improves thereon,and
who contracts for such prejects with a contractor(s)limmad pursuant to Ne Contractors
manse law.
❑lam emptundm See .B&PCfar this mason
GU Data2-�o3�oy.
WORKER'SCOMPENSATION B\B[L'ARATION
1 hereby aRtm under penally of perjury ane aFRe following dedauiou:
I hew end will maintain a Certificate OfCaaenua SCINOsum for Workees Counter'
aria.,a provided far by Section 3700 of the labor Code,far the perform..of the
work far which this permit u issad.
t]1
have
and will maintain Workers Compensation Insurance,u required by Section
3700 of No Inbar Code.for Ne performance of the work for which this permit is issued.
My workers Compersatlon Insurance carrier and Policy number em:
Cartier. Policy No.:
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(This section sed not occamp Ieted Vince permit is for one hundred dollars(SIM)
or lass.)
1 anify Nat in the peffroperM of de work for which this permit is issued.I shell not
employ any peran In any manner an az at become subject to the Workeri COmPensalion
Laws of Califoroia.Data
APPlicant
NOTICE TO APPLICANT:If.after making this Certificate of Eacmption,you shouW
become subject o the Workers Compewdon provisions of the,Labor Cade,you muss
O forthwith comply with such provisions or this Permit shell he decmcd revoked.
'Z� CONSTRUCTION LENDING AGENCY
t:+ I macbyoflirm Nat there is a communion Icadingagency lot the Performance of
Cat No work fur which this permit is issued(Sec.D9].Civ.C.)
0.i A Le der'.s Nansu
7 z Leal . dos
U G 1 asify that 1 have read this application sad Nm Na Ne above information is
ly P correct.l agree to comply with all city and county ordinances and sum Is"misting a
0U building construction.and hereby authodm representatives of this city to an=upon the
Lu above-meat oned property rot inspection purposes.
y (We)agree to ave,indemnify and keep harmless the City of Cupertino against
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liabilities,judgments.mass and expense which may in my way ammo against said City
UZ in mmaeguance of Ne gsanting of this Permit.
^ APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT Issued by: Date
SOU EREGUfA ONS UO3/O
4 Re-roofs
ut
gnatu'a of Applic HAZARDOUS MATERIALS DISCLOSURE unro Data Type of Roof
Will No applicant or future building uaupartalom or handle haurdeas material
a dented by tie Cupertino Municipal Code.Chapter 9.12,and the Health and Safety
c,Sectio.25532(e)? All roofs shall be inspected prior to any roofing material being installed.
❑Ya. o�
Will the applicant or future building mxumm use equipment at dcvica which If a roof is installed without first obtaining an inspection,I agree to remove
.it haardous air contaminants de0red by the Bay Area Air Quality Management all new materials for inspection.
District?
❑Yes Nu
I have mad the hasrdous materials requirements under Chap or6.95ofthe Califor,
ma Hwlth&Selcty Cock.Savau 23505,25533 am1255X.I undersand that if the Wilding
docs not currently time a tenant,mat it u my micanaitnlity a notify the Occupant Of the
no uimmcnu�yhi-chra: Ee met br m lamance oft Certificate of VPanq Signature ofApplicant, Date
I�IY 7 l0' ��L( g
Owner or aohmiacd agent Data All roof coverings to be Class "B"or better