08080031 CITY OF CUPERTINO
BUILDING DIVISION PERMITCOi�ITRACTORINFORMATION
9A a"Fmd<'1;: :;.ali T
BUILDING ADDRESS: PERMR NO.
10227 EMPIRE AVE LOT 1 TBD - TO BE DETERMINED 08080031 '
OWNER'S NAME: PERMIT ISSUE DATE
OCK IRI
NE: SA CONTROL NO.
ARCHITECTIENGINEER: BUILDING PERMITINFO
NEW 2-STORY SFDWL LIVING BLDG ELECT PLUMS MEcx
woo LICENSED CONTRACTOR'S DECLARATION 2, 560 ' W/ATTACHED GA%rpDescri tion
u 1 kreby affirm Nat 1 am lucnacd uodcr provisions of CheplCr 9(commencing _ ^T P
it Section 700)of Division 3 of W Business aod Profcssimu Code.and my license ire
in full fame and effett
j License Class Lie.0
Dao: Camnctos
I" ARCHITECTS DECLARATION
il1 umWeua
rnd my pwm mail Ac wool a While recast;
s
D60
!G G< Lm.hacd Professional
w0J OWNER-BUILDER DECLARATION
<x I hereby aUIm that I am exempt from to Convector's License Law for me
❑O following ream..(Savo.7831.5,Basi.and Professiom Cade:Any city or..my
$r which requires a permit An convect,alter,improve,demolish.or repair any shuetum
_Zm prior to its Issuance.new requires the applicant for such permit t file a signed statement
< mat k u licensed punsant to she provisions ed to Comratr's License aw(Chapes9 Sq.Ft. Floor Area Valuation
Y~$ (commencing with Sedco 7000)of Division 3 of roc Business and Professions Code)at
I mu he u emmpt muefrom and to basis for the alleged nxempdat My rMladun of
Section 70315 by any applicant two permit wbjecu to applicant w a civil Penalty of APN Number Occupancy Type
ant most Tao five hundred dalWs(SSW).
1,as owner of the property,Or my employees with wagca as door sole compensaskn.
will do to work,and to mtrwctum Is not intended or offered M.M.(Ser.7014,Business
mast Ptofesslom Code:The Conmeme,License Law does nut appy t an owner of Required Inspections
property who builds m improv tkrco.,andwha doessuchwmk himselfor Waugh his
we employees.prswided that such improvements are not intended oroffmcd(orale.if.
however.W building or improvement U mid within one Year ofcampletuon,dee owner,
Authors MO Now the burden of pmHng tat k did rot wtuw m Improver for purpose of
tAs owner of the Property,ma exclusively conhmting wide licensed contractors m
I,
tract to project(Sec 7044,Business and Professions Cade:)The Contrauitr's Li.
come law does out apply in an owner of properly who builds or improves thereon,and
who contracts for such projects,wit a contractor(s)licensed pursuau As W Contractors
Lkanm Law.
01ron rep n rSAO ,B k PC fee this ream.
Date
WORK S OMPENSATION DECLARATION
owner
1 hereby Nim uncle edaily of perjtuy arc or the following decimations:
I ham and w0l mansin a Ccnifievw of Comm w al(-i...re for WtolmesCompem-
mvan,uprovided for by Sanson 3700 of W labor Code,for dee pesfamance of me
work for which this posted is issmed.
❑I have and will maintain Worker's Compernatlan insurat As mquird by Section
3700 of we fabs Code:for the pofaman.of to work for which too .it it issued.
My Worker's Compans"on Insurance artier and Paliry,number ase:
Cama: Policy No.:
CERTIFICATE OF EXEMPTION FROM WORKERS
COMPENSATION INSURANCE
(ThoseNsm Iced Out becompic d if to permit Is for ane hunstmd dollars($100)
or Ins)
1 cenify tat in to perfomaae of dee work for which this permit is issued,l dull not
employmy person in my mannorm t rpe subject to the Worken'Compersadon
laws of
if
O PO
r/d
Applicant I// it
bco
NOTICE TP CANT:IL.{er ma ting mu CcsiiBwt of Exemption.Co.you shawls
�Obecome subject y ret Worker'! eons x thea ound,m l Of do labor Code lyre comm
foMwide rnmP1Y wit melt Provisions m to Pen^.it mhal be deeded reroted.
z " cohimUCT10NLEADINGAGENCY
'row��+ 1 hucbY grim sive Wre u a commNnn knding agency for W pMomance of
Ci W work for which this pemeit Is issucd(Ser.3097,Civ.C.)
A Undoes Name -
z Lemines Mdoess
V Q 1 century mu I have mad No application ad Blom mu to above information is
lL F
context.I agow On comply wire all city and county ordinances arta slow laws rcwvng to
.0 U building consemcdan,and herebymalomise rtPreo^sdvcs oftis city to cmcruponW
W alevc-mentioned Property for inspectin purposes.
(~gy (We)agree he ave,indemNfY and kap homeless sw city of Cupertino against
rn liabilities,jus vents,cord and expense which may in my way aaxuc agamt aid City
nectfamen Or to&OLVIng Of
s permit.
V z APPLLICA UNDERSTANDS AmND WILL COMPLY WITH ALL NON-POINT Issued by: Date
SO! R A 0 S. JIJ/ O
^ Re-roofs
Signiuma OT App ism a Bw
HAZARDOUS MATERIALS DISCLOSURE Type of Roof
Will the ap,liamor future buildingaauPmtawm or lundl hararduus materia
As de8rcd by the Cupertino Municipal Code,Chapter IIAL and the Heat and Safely
Code.statim M532()7 roofs shall be inspected prior to any roofing material being installed.
❑Y HNa
Will me applicant or futu\re building Occupant um equipment u dews which If a roof is installed without first obtaining an inspection,I agree to remove
emlt hurardous air contaminants As deriocd by the Bay AMA Air Quality Management all new materials for inspection.
Disuicff
❑Yes y
I have mad me Avardous materials nequhcmcnu under Chapter 6.95afine Califar-
meHalt hSolely Code.Sections 15505,75533 aro 25534.1 uodcr.and tcifW building
does not cumody have a tnank dew it is my mvpomihilimY t homily the oaupmt of the
require 'h bemet .man issuumooa Cemdaamofacepns, Signature of Applicant Date
Owner umhasrsd Agentf 'I '
All roof coverings to be Class'%W'or better