08100189 BUILDING DIVISION PERMITkC�F!ITRACTQRTi�}k�ORMATIaON
BUILDING ADDRESS: PERMITNO.
OWNER'S NAME: PERMrr ISSUE DATE
p SA CONTROLNO.
ARCHRECf/ENGINEER:
BUILDING PERMRINFO
BLDG ELECT PLUMB MECH
NEW ORTHODNTCS OFC W/T—BAR 2 O O O D
°oo LICENSED CONTRACTOR'S DECLARATION ADABTHRMS, PRTN Job Description
w❑ 1 barely affirm that 1 nlam licensed urds r provisions of Cloister 9(Commencing
iW with Scetion 70W)of Divi II or to Theicess and Prokasiom Code.and my license --•- - ^^••^^^••^ - ^^^- - ---
R
in full force and.Beet
j ? Litems Class Lie.0
=Fp
Dam.Contractor
en f', ARCHITECTS DECLARATION
t m 1 understand my plans shalt he used as public words
JyU
porn Licensed Pmfcssionsl
5 Oat I am exempt
from
m CLARATION
00 1 masa .Warm that 1 1. eBumpt from the Cmions, a License Law for Ne
p O following reason.cninit t 7I3 Lm,Business and improve.
de io demolish,
Cod.:Any city or county
yon which its isunpermit mcnnswcL dtsr,improve,dcermiti fie a sig anyswctum
-I6 pnmmitscensedpursuamgoima tW applicant for such Contractor's
Bcirm Lawdsu¢mcm
EZ thot hmenci gwJpursuaonto the on 7")ofDivinnso of theBusines''andProfsionChap¢r9 Sq.Ft.Floor Area Valuation
F R Oat he s exempt dictation
and
the
basis
r O the Mined
Business and on.Any00r Cud.)or
y R$ Nat he V exempt Ncmfmm and the bus for the alleged exemption.Any violation of
Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of APN Number Occupancy Type
out more On five hundred dollars(5500).
❑I,as owner of the propeny,m my mnploycns with wage vs their sale compensaden,
will do the work and the swctum H not intended or offered ferrule(Sce.RMA.Business
and Pmfessums Code:The Communions Lk.Law deer not apply m an own-of Required Inspections
progeny who builds or improves thereury and who doe such wart himse if or through his
awn employees.provided that won improvements art not intended or offercA forests.if.
however.the building or improvement u sold within one you of mmptedon,the owner-
builder will have the burden of proving that he did not build or improve for purpose of
sale.).
1,as owner of the pmpeny.am eaclmivcly contracting with licensed contractors to
Co outs the project(Sec.7061.Bnsinev and Protirssions Code:)The Conuam res U.
Cent Law it.not apply m N ewTef n(propn improve Hewn.and.
wWcontrscufor,oelsons, uwithaei nsdpursuantmdre Cenuaetors
litems law.
1 son exompt un .B&P C fon this mown
Dots
WORKER'S COMPENSATION DECLARATION
I hereby aQum under Geral ty of perjury arc a(the(ellewing d-laruions:
(]Ihsmandwitimainuina C-tiGnuof C...it self-inwrefh-WarlefsCompen-
rztion,as provided for by Section 3700 of the Labor Code.for the performance of the
work for which this permit is issued.
❑1 have and will maintain Workers Compensation Insursme,u required by Section
3700 of thc labor Cade,fm Ne pcRormana tribe work for which Nu permit or issued.
My Workers Cooperation.Immource emcr and Policy number -
Cnicr. Policy No.:
CERTIFICATE OF EXEM MON FROM WORKERS'
COMPENSATION INSURANCE
OTusmien treoil..,W c-nple¢d If tic permit is Innen.hundred dollars($100)
or Ina)
1 certify that ionic perfonnancemf ibawoik yy hich NB permit is issued,l shall not
employ any person in any��
na dyne u to t2o the Workers'Compmadon
Laws of California a¢
Applicant
N APP AINT':IL a r making fiCenificats of Exemption,you should
oma subject in the W000n s Compensation provisions of the labor Code.you most
forthwith comply with such provisions or this permit shall W deemed nooked.
'zO CONSTRUCrION LENDING AGENCY
[-+ I hcmby affirm that there isa,tutmctinn lendingapemy for the perfurmmta of
fX> the work for which this permit is Wood(roe.W.Civ.Ca
iq Lenders Name
7 z Under's Address
U Q 1 certify that I hors read Wa application and nam that the shove information u
F MMOL 1 agw to comply with all city and county oNinuues and sum laws relating in
p U Wilding Construction.and hereby wthonserepresentatives of this city to cuts,upon the
r{A above-mcndoned property for inspection purposes
agree to fare.indemnify and kcep harmless the Cit of Cupertino against
In Iiabilidexpoliments.ensts andexpeues which mayj true against said City
U',Z in cortscquence of the granting oti this udL�
^� APPLICANT UNDERSTAN OMPLY WITH ALL NON. INT Issued by: Date Z �
SOURCEREGU
_ Re-roofs
u HAZARDOUS MATERIALS DISCLOSURE/or am Type of Roof
Will the applicant or future Wilding occupant Mom or handle haaallous material
as Cleared by de Cupertino Municipal Code.Chapter 9.12.and the Hcalth and Satiety
Code.sextion25m32(a)7 All roofs shall be inspected prior to any roofing material being installed.
40 ❑Yes No
Will the applicant or flrt Wilding occupant tau equipment or d vias which If a roof is installed without first obtaining an inspection,I agree to remove
emit ha,inho s air contaminants u defined by the Bay Area Air Quality Management all new materials for inspection.
Msrrmt7 {
0Y. gift
Ihe,.read the hareaadous mwerhisrtyvirtmc r6.95.fthCCMifm-
nia Health&Safety Code S-dmu 25511 .I undesund that iftht Wilding
it.not cumndy hens a to map:m;bility m notify the occupant of rhe
m9oimm.ntswhi r issuanceofaCcrtifeatsofOmp Y. Signature of Applicant Date
/ y r
caner or sumo red ascm All roof coverings to be Class'"Or better