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CITY OF CUPERTINO"'C'
BUILDING DIVISION PERNIIT CONT, RACT Ii'OsRM A'ION
BUILDING ADDRESS: PERMITNO.
OWNER'S NAME: PERMrTLSUEDATE
0 . AmERIeAA CONTROL NO.
n In escmn
(408)942-8200
ARCHLIECTtENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
0 0 0 0
LICENSED CONTRACTOR'S DECLARATION lob Description
I hemby amrm �t 1 w l�nsm under provisions of Chapter 9 feco meneing P
with Secdon 7") of Division 3 o de Business and Profcasiurs Code. and my license u
In follforcemellen �!) COMM'L TI NEW FULL HEIGHT OFC PRT'S, RELOCT
Licenw Class Lk.g
Dam — —o ContracWr — BTHRMS, 2 NEW WNDWS&4 NEW SKYLGHTS& NEW FINSHS
ARCHMCTS DECLARATION
[understand my of. shall be slid u public..ob, THRUOUT 9686SQ
Licensed Poicstional
OW NER-BUILDER DECLARATION
I hereby amrm that I am crempt from the COnhucmfs License Law for the
foilowing .. (Section 70313. Business am! Proles m. Cede: Any city or minty .
Which mci i. a permit m cMLrack allies. YnpmYe. demelkilt. N repair any wuelme
prior W its issuance. slant mquoss the.Pplleam for.1i Permit m file. signed susment
Nu he is licensed Purpunl to the P.Asicu of the Committees Lkcts¢ Low(Ch.Ptc 9 Sq. Ft. Floor Area Valuation
$ (eommcming With Section 7000) of Division 3 of the Business and Professions Code)or
—
that be is exempt therefrom and Ne basis for use alleged exemption. Any violatfon of
5600000
Section 7031.5 by any appBcant f. a permit wbjeets use applicant W. civil finitely Of APN Number Occupancy Type
not mare dun fire hundred dollars (M). P Y YP
❑I,uownerOftiie property. err my wplayeos with wagnvdeir wk comPenution, 32633079.00
will do the work, and the suunum is not intended orofRmd for see (Sec. 7061. Bue.
and Professions Code: The ContrcmYs License LAW conn rot apply W w Owner of Required Inspections
Property Who Wiles«improvsi Nnwo. andwW doesauchworic himself. through his
awn employers. provided that such improvements am rot intended. of errd f. sale It.
las aemr. Ne building. improvement is sold within arc year Of completion, the nwver-
Wilder will berm Ne bud, of proving wt Ise did out Whol .Imprme f. purpose of
ask.).
0 1, u owner of lit Property un exclusively convecting with licensed onnuanOrs W
m 1.1 use, project (Sec. 7044. Business and Profesimns Cade:) The Commenor's U.
cense Lw Occur not apply W m owner of property who Wilds or imProvns Merton, and '
who contracts for such projects with aconvacmr(s) licensed pursuant W the Contnctuls
Lkercm Law.
❑I oro exempt sneer See ,B h PC f. Nis myon
Dau
WORKERS COMPENSATION DECLARATION
liter 1 hereby affirm under penalty of Perjury One of the following deslvationu
❑ 1 M1am and w0I mainurn a CerdOcate ofConsenl W self -ilium (. Workefs Compeo-
ution, u provided f. by Section 3700 of the Labor Code. for the Performance, of tie
Wort for which this permit is issued.
0 1 have and Will maintain Work:es Compensation Ivuronm, u rociuired by Section
3700 of Ne Law, Code. for the Performance of Ne WcA for which Nu permit b issued.
My Wmkefs
FROM WORKERS'
COMPENSATION INSURANCE
(Thasectlon rcsd rot be e.npkrcd if the permit Is fame hundred dollars (SIM)
or less)
1 c.tify that in the performance of the work for which his Permit is issued. I shall not
mn,I, any Person In any m011Kfw as W become subject W ft Wotkers' Compensation
Laws Of California. Dee
Appllcant
NOnCE TO APPLICANT: If. after making this Ceni5caW of Exemption, you should
become subject W the Workee's Compewtion previsions of the Labor Code, you most
Oforthwith comply with such provisions or this Permit shall M deened rtvokcd.
CONSBUCTION LENDING AGENCY
> I hereby affirm NU Nem isaconuruction kedingagemy for the if.. of ,
tiic work for Which Nis Permit is Wood (Sec. 309'1, Civ. Q
lender's Name ,
z Lenders Address;
Q I certify Ne 1 have end tris application and site the the above information is
Fcomcct. I agree W comply with ill city use co my uNir aM, and sus laws relating W
U Wilding construction, and hereby wlhodre reprnsmudms of this city W corer upon me
LLj alwvc-mentioned propcny for inspection purposes
(We) agree l0 mom, indemnify and keep barmku the City of Cupertino against
T4q Iiebilides.judgin.macosu and.sre. Which may in any wayscencaguvsssid City
Z
APPLII oNDER ANDS As q WILL COMPLY WITH ALL NON -POINT
Issued by: Date
SOUR
Re -roofs
sigmaure fApplicanuCan rI tk Data
HAZARDOUS MA AIS DISCLOSURE
Type of Roof
Will than applicant or fretum Wilding oecupwtu.c Or handle hasNo. maWrial
in defined by the Cupeniom Municipal Code. Chapter 9.11. and use Health and Safety
Code, Sccdon 15532(.)?
All roofs shall be inspected prior to any roofing material being installed.
Yu o
If a roof is installed without first obtaining an inspection, I agree to remove
Will the applicant or forum building Occupant use cyuipmem Or deviru which
col hazard^us air contaminants u do0ned by the Bay Ares Air Quality Management
all new materials for inspection.
DisuinT
❑Yrs �o
Iham mad Ne erhbrequiremmtsumkraapWr 6.95OTNcCaiifor-
nuNnJoha"etyC Sec4.0 SOS.u537 uW13534.1uMvsund Nuifde bdlding
dons sun Y antrum. L4t it my responsibility in mify, tiic.cupul of de
roy reaWoro-wpawy.
Signature of Applicant Date
Z4-
All roof coverings to be Class '%T' or better
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