08120129 CITY OF CUPERTINO
BUILDING DIVISION PERMIT ° CONTRA. 'TOR ' 'i�' LMA.TIa
BUILDING ADDRESS: PERMIT NO.
ER'S NAME: PERMIT ISSUE DATE
PHO , 3675 SA CONTROL N0,
ARCHIIECTIENGtNEER:
BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
REPLACE SKIMMER 4 RETURN O O O O
o" LICENSED CON RACrOR'SDECLARATION SWEEP & FILL LINE,' NFJWb Description
�w 1 boseby affirm Nu 1 un 1'ixnsd under provisions of Chapter 9(commencing
< with Sation 70(1())of Division 3 of the Business and professions Code.and my Ike=is -•^ ^_�. ____ /
0
i tiice�auss d errttr.G S� Lic.• 72-6772
nF� Date ConlDECLARATION ARCHITECTS DECLARATION
D.0 IundcmunJ my pWuslWlWusW" ¢
public cord
1.0
y licensed Professional
u'
''y ONER,BUILDER DECLARATION
jE 1 hertby aRrm Nat I am Cotentin from the ComrscOes License law ran the
ZOO following rtamn.(Section 70 i.S.Bmrncsa and Prefessiuns Cale:Any city m county
i which¢quires a pmmit he corn en,alts,improve.dmmish,or.,it any sduaurt
prior to is issuance.alts,hope.the.,Iic.t no,such permit m file a signed mo mem
<
that heis licensed purvan tofprovision ofthe Conu¢uNsLicense Law(Gaptm9 Sq.Ft. Floor Area Valuation
y1-- (commencing with Section 700M of Dindon 3 of the Business and Professions Code)or
y $ that he is exempt therefrom and Lha bout for the alleged caempdon.Any violation of
Section 7031.5 by arty applicant fm a permit Sebjccs the applicant m a civil penalty of APN Number Occupancy Type
not more than fin hundred dollars(5500).
L as owner of Ne property,or my employcas with wages as their sale competwtion,
will do the work,and IW structure is non intended or offered for sale(Sec.7014,Business
and projections code:The Commerce,Liam.Law doe art apply in an owner of Required Inspections
property who builds or im proves thumn,and who doessac h work himsel f rr through his
awn employers,provided that such improvements ase not intended¢offered for We.if.
however,the building or improvement is mid within one yin dcompletion.doe owtsr-
builder will have ds burden of proving that W did Out Wild or imprm s for purpos of
sole.).
1,as mmcr of due property.am"elusively Contracting with licensed consacmrs to
commoner the projea(Sec.7004,Business and Profnssions Cade:)The Contractor's Li.
cesse Law does not apply m an owner of property who Wilds or improv"demon.and
who contracts for such projects with a contractor(s)licensed pursuant to the ConoramaYs
Lice".Law.
❑1 am exempt under Sec. ,B&P C for this msaon
Date
WORKER'S COMPENSATION DECLARATION
I hereby affirm under penalty of perjury one of the following declarations:
❑1 have and will maintain a CertlOeave of Consent W self-insum for Wrrkm's Compen-
Colon,as provided for by Section 3700 of the Labor Code,for Ne,performance of de
work for which this permit is issued.
1 have and will maintain Workcls Compensation Insurance,as squired by Section
3700 of Ne Iebar Code,for use perfmmm.of the worts for which this permit is issued.
My Workcc(e�ss Compensation lasumal carrier and Policy number are:
Carrier..[H 0/3SR1 Policy No.: Q6I L'V1017�
CE FICATE OF EKEMP ION MGM WORKERS'
COMPENSATION INSURANCE
TW;section(teed rat W completed lithe permit is(ajar hundred dollars Shall
or lex)
I comfy Nat in the parformvze of IW work fm which this permit s issued,l shall not
employ any person in any mmmrm as m become,subject to the WorkerCompensation
Laws of Califomia.Date
Applicant
NOTICE TO APPLICANT:If,after making Ns Cenifit of Exemption,you should
become subject in the Work s Compensation pmvsiost or the L ar Cade.you most
.,z foMwith Comply with such pmvsm
ions or this permit shall W deemed revoked.
z 2 CONSTRUCTION LENDING AGENCY
[-.4 Thereby affirm that there is a construction lending agency for ds performance of
!Yi > Ne,work for which dust permit is stood(Sec.3(y97,Civ.C.)
GQ Lcnder's Name,
:D z lender's Address
U C) I comfy Nal 1 have mad Nis application and sum door IW shove info rmuum s
6. P cortin 1 agree to Comply with all city and county ordinances and sure laws relating be
0 Wilding Construction,and hereby mlods represamatives of Nu city to enter upon ds
aWm-mentioned property for inspection purposes
F 1 (We,)agree to save,indemnify and kap humins the City or Cupertino against
ti liabilities,judgmcros,Cosa and..,ensu which may in any way...against said City
U z in consequence of the gransng of this permio.
^� APPLICANT UNDERSTAND AND WILL COMPLY WITH ALL NON-POINT Issued by: Date
SOURCE REGULATIONS.
�'- 12122108 Re-roofs
Signuure of ApplicaHAZARDOU / D
HAZARDOUS MATERIALS DISCLOSURE Type of Roof
Will ft
ue Cupertino
or rumre Wilding e,Chapter
or handle hmvdaus material
u defined io Ne,Cupertino Municipal Code,.Chapter 9.12,and Ne Health and Safety
e.
section 25532(a)?
❑Yu N11. All roofs shall be inspected prior to any roofing material being installed.
Will the applicant or future building occupant use equipment or device.whim If a roof is installed without first obtaining an inspection,I agree to remove
.mit harardnus air contaminants as defined by the Bay Area Air Quality Management all new materials for inspection.
Distrito?
Q Ycs �No
In=mal Ne hvamsnsmaterias Mquiremens under Chapter6.95 of the Cahlor.
nia HcalN&SmctyCWc,Secua 25503.25533=dMM.1 undersand tiuif Ne Wilding
does not Currently hoc a u nam,Out it is my mapomibility Is notify Nn Cu,.,aof Ne
rtqummcns which mu met .a an«era CemIII oroccmpmey. Signature of Applicant Date
Owncroramhor cot D
All roof coverings to be Class'W'or better