08110095 CITY OFCUPERTINO � sxs ;~ "- �•' •`'
BUILDING DIVISION PERMIT #COt�ITRACTOR I�1FUTATTON �.
BUILDING ADDRESS: PERMfr NO.
21979 SAN* FERNANDO AVF RnRRRT
OWNER'S NAME: PERMIT ISSUE DATE
8 8 CONTROL NO.
ornnrt
(408) 279-2277
ARCHRECTIENGINEER: BUILDING PERMR INFO
BLDG EIECT PLUMB Mmm
0 0 0 0
uOo LICENSED CONTRACTOR'S DECLARATION lob Description
uF 1 hweby afriov Wt 1 am lke uokr pmvisions of Chap=9(mmmcacing
^,Tj t3 wii65¢dm70to)ofDivirion3offt Buvvncsand Profeswns Code.and my license is
to full fence and ercut RMV OLD BLDG; 2 OLD INACTIV RESTRM BLDGS & PARK
y
III-z License ChisLie a
Dam Contractor MAINTNANC SHEDS, OLD ICE HSE
y ARCHRECrS DECLARATION
I understandds
my piano shall W used as public recor
W U
Licensed Prefcasiend
5 OWNER-BUILDER DECLARATION
I hereby al7im Nn I am attempt from 1W Conlnnoh License Law for the
Oo following reason.(Section 7031.5.Business and Profcuium Codc:Any city Or county -
y$ which require a permit to cts.s,She,improve,dcmolbh.w.pair any soucome
prior re its issuanm.also require theapplicant for Such permit to Monsignors ststemem
that Wis licensed pursuant to the provisinnsur lM Comment,;Umm Law(Chapter 9 Sq.Ft.Floor Area Valuation
z€� (commencing with Section 70W)nf Division 3 ofd.Businrssand Proressinns Code) 1
y Nat M b eumpt therefrom and the basis for the alleged exemption.Any violation of
00
Salim 7031.5 by any applicant for a permit subjects 1W applicant to a civil penalty Of APN Number Occupancy Type
ver ren.thmi BK hundred dollars(SM. 35710005 . 00
❑1,n owner of 1W Property.or my employee with wage as inch role compematim,
will do the work and Mcatncture boot intended or uQertd for sale(Sm.Blit,Bumuse, Required Inspections
W Procodons Coda:The Counselors License law,docs ret apply m as owns e Of q P
property w he bui Ida w impmvts thaeen,and who does such work him elf or through his
Own employ=.provided that such improvements an,not intended oroRe.d forsale If.
however,the building or improvement Is sold within arc year of complmion,Ne owner,
builds,will law the burden of proving that he did not Wild or improve for purpose of
s--ale,,.). .
S,,as arm of lite pmpeny.Sm ealuaiwly contracting with IseosW comracters to
mmmue,rise project(Sec.7W.Businm and Professions Code:)The CmoactNs U-
conse law does not apply or an own.of Property who Wilds or improve thercon,and,
wW contracts for such projects with aconuacmr(sl Ilcaved pursuant m the Ceetramors
Licevx law.
❑tun pt under Bee ,B&P C(m this.awn
m IAA. TION T
WORKERS MPENSATI lOECLARATION
I hereby air=under penalty of perjury one of tie felbwing declarations
rat❑1 have and trill t for bins ee m 3700 of Covent r selftlinsure for WOrkdaCmpeo-
wwIcfr pmvidhi for by Section 3700 v(de labor Code,far the performance Of 1W
wok far white this permit is issued. '
❑I have and will maintain Workers Compensation Nunn.an required by Section
3700 of the Labor Code.far the penormance of Ne work for which this Rmait is issued.
My Workers Compensative haenm ca.ier and Policy numbs K:
Cartier. Policy No.:
CERTIFICATE OF EXEMPTION FROM WORKERS
COMPENSATION INSURANCE
frais sconon wood Out uncompleted lithe permit Is formic hundred dollars($100)
orMost)
1 certify Nat In the Perfortance of the work for which this Permit IS wood.1 SMI not '
employ any person in anyannro oWi mevbjenmlM Workers''Compensation ' -
laws of C.lifqi.Dam
Applicant &a.J.s...
NOTICE TO APPLICANT:IL after ffiakinj this twricatc of Exemption,you should
become subject m the Waters Compensation provisions of the Talar Code,you most
.J O forthwith comply with such pmvM(MS Or this permit Shall W m
deeed ke
revod.
z"' CONSTRUCTION LENDING AGENCY
I hereby affirm dolft.is a construction lending agency for the pmformari¢of
{Y i lite work for which this permit Is issued(Sec.3097,Civ.C.)
G0 leaders Name
,0 Lenders Add, .
U C I minify that I have rW this applicadon and sum teat 1W above information U
P comet 1 agree to comply with N city sed county onlinanw and sum laws relating m
-QU building construction,and hereby authodsa.p.xnudves of the city Or uW
w ab.-mmnioned pmia ny for inspection purposes
gy (WO)agree W Sam indemnify and luep harmless 1W city of Cupertino against
fn Iiabilitin,jWgmmus.cases and eapousas which may in any way canoe agaWt said City
U Z APPPLLIceptence of the gounfing Of this CANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT Issued by: Date
Sry+�CE 0.EGULATI ' '
rgag&lk Re-roofs
Sigwum of Applicantnt>rmr �—
H DOUSh ALS DISCLOSURE Type of Roof
Will the applicant w future Wilding OnvWL store or handle hazardous material
as&Read by the Cupertino Municipal Code.Chapter 9.12,and tM Hcdth and Safely
Cove,Section 255321.)7 / All roofs shall be inspected prior to any roofing material being installed.
❑Ye _/ All
Will the applicant or future Wilding Occupant use equipment Or devices which If a roof is installed without first obtaining an inspection,I agree to remove
colt harardons air contaminants a defined by the Bay Area Air Quality Management all new materials for inspection.
District? �
0YU &No
1 have mad theharaNuns materials mWhenteres under Chapter6.95ofOm Califor-
niaHcalth&SafciyCOdc.S dom M5 .n533am)25534.lwdc.undthuif Nc Wilding
does ret currcmlY into a tenon,this k is my.SponsibilitY m ratify circ mumon of Ne
.fy`��y.mcnu win h etpnorminu�mi�«yofacrnireamofaenp.n Signature of Applicant Date
`
iAAe,,rcrwouthomad agent X�--� Damam I[�25� All roof coverings to be Class'."or better
—
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