08120086 CITY OF CUPERTINO t ' :a
BUILDING DIVISION PERMIT CONTMA', -,R'I N. ORMATION'�n.
BUILDING ADDRESS: FERMITNO.
OWNER'S NAME: PERMIT'15511E DATE
O , A CONTROL NO.
(408) 225-9992
ARCHIIEL7/ENGINEER:
BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
X00 LICENSED CONTRACTOR'S DECLARATION
.51 bmcby affirm that I am licensed under provisions of Chapter 9(commencing Job Description
0z da with Section 700(l)of DIN 3efdoeBusncnand Professions Code.aMmyliecvcis
+�H inrmlfomcatWeffat ^� /J- CONVRT SNGL NON—RTD DOOR IN NON—RTD NON—STRCTRL
DLJZ Lioneen Class Lic.g d R m tl1
Data comrmter WALL W/DBLE GLS DRS
^� ARCHITECTS DECIA ATION
2 1 understand my plans shall W used as Public me.,&
JdU
k 0 Licensed Pmrcssionel
5 OWNER-BUILDER DECLARATION
va
.� I I Wrehy affirm that I em exempt from Ne Conuacmfs License taw for the
O o following myon.(Section ZID L5,Business and Rofenions Code:Any city or county
3$ which requires a Permit to convect,altar.improve,demolish or repair any Structure
Z< prior to its issuance.also¢quims the applicant for such permit o file a signed statement
that he la licensed pursuant to the provisions of dm Contrazmr's Ucenm Law(Charles 9 Sq.FC Floor Area Valuation
YFG (commencing with Section 70)0)of Division]of the Susan,and Pearcesiom C,mc)or
y 5$ that he is eaempl therefrom and the basis for tie alleged•..mpuon.Any violation of
Section 7031.5 by any applicant for a permit subjects thin applicant to a civil Fatally of APN Number Occupancy Type
not mom than five hundred dollars(SSW).
01,a owner of im property,Or my employees with wags as their sole compensation, 31621090 . 89
will do the wort,and the stmcmre is not attended or offered for sale(Sec.70th,Business
and Raressions Cada:The Contractor's Lica¢law does net appy to in owner or _ Required Inspections
property who builds oriceproaes them est.and who does suchworkhimselfarthrough his
owncmployces,provided Chet such improvements ate not intended oroffnred for ale.If,
however,the building or improvement is said within arc year of completion.the owner.
builder will have the burden of proving that he did not build or improve fm purpose of
sate.).
❑1,as owner of the property.am exclusively...trading with licensed contractors to
consuun the project(Sec.7044,Business sad Professions Cade:)The conaacmYs Lt.
came Law does not apply m an owner of property who builds or improves amreon,and
who contracts for such projects with a conbactor(s)licensed pursuant to the Comractaes
Lu me Law.
[3 lamexemptunder Sec. ,BdPCfarthisomme
w e
Data
WORKER'S COMPENSATION DECLARATION
I hereby affirm under penalty of randury,ane of the following daclamtiom:
have and will maintain a Cctifmcam of Content to selr-insure for Workab Compm-
saion,a provided for by Section 37W of the Labor Code,fm the performance of the
work fes which this permit is is ed.
1 ban and will maintain Worker's Compensation Insurance,an required by Section
37W of the labor Code,far the perrormanee of the work for which this permit is issued.
My Worker's Compensation loan...carrier and Policy number are:
Carver. Policy No.:
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
fruit action sed Out W completed if the Permit is forone hundred dollars(3100) _
or less)
I certify that in the performance of the work fes which this permit is issued.I shall not
employ any person in any mamerso a in become subject in the Wor icn Compcatsadan
laws of Califumla.Dam
Applicant
NOTICE TO APPLICANT:If,after making this CcniOcam of Exemption,you should
become subject in the Workeri Compensation provisions or Ne labor Code.you must
,J z forthwith comply with such Provisions of Nis permit shat]W deemed revoked.
z " CONSTRUCTION LENDING AGENCY
[—m I bereby aPrm that there is a coreariewin lending agency for dee miummnce of
a the work fur which NU Permit is Wood(Sec.3097,Civ.C.)
W 0 Undoes Name
7 z lender's Add.
U C) 1 certify that I have read this application and mm dm the above Indonesian is
coarct 1 agree m comply with aR city and county undinancu and sme laws relating m
0 building aomwctian,and hereby mutation MPmaeetatian of this city he enter upon the
La marc-mentioned property for inspection purposes
(We)agree to new,indemnify and Race harmless the City of Cupertino against
F'h liabilities,judgments,costs and expenses which may in any way see=against aid City
V z in consequence of the granting of this permit. -r
APPLICANT UNDERSTANDS AND ILL COMPLY WITH ALL NON-POINT Issued by: Date -
SOUR�gREGpLrONS. .�
- !L��. L t Jew" Re-roofs
Sign uen of Applicaut Conuacmr Dam
HAZARDOUS MATERIALS DISCLOSURE Type of Roof
Will um applicant or forum building occupantsmm or handle hamedma material
as defirod by the Cupertino,Municipal Code.Chapter 9.12.and the Health and Safely
Carle.Section 25532(01
All roofs shall be inspected prior to any roofing material being installed.
Will the applicant or future building Occupant use equipment or devices which
If a roof is installed without first obtaining an inspection,I agree to remove
CML ha%atlOus air contaminants as defined by the Bay Area Air Quality Management all new materials for inspection.
District?
❑Ya u
I have real the haaardrta mamriab requimmcnts under Chapmr6,95 of the Ciliror-
niaHcahhh Safety Cadc.Savour 25505.25535 anti25534.I amlcmtand thatf dm Wilding
docs not currently have a tenant.that it is my remonsibiliy m mmury the reement of the
myuirtm��c nw••Ncb m"Wmct ' rmv coma catiecama s�Jc/up/yes/ry� Signature of Applicant Date
X;�
Own onuthariacd agent Dam'
All roof coverings to be Class'A"or better