09050043 CITY OF CUPERTINOXX
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77��*� �J • ,
BUILDING DIVISION PE1�1Y111 N N10W�
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BUILDING ADDRESS: PERMIT NO.
204
OWNER w
'tSr5 0 INC.
PHONE S CONTROL NO.
ARCH TI:c T/ENGINEER: BUILDING PERMIT INFO
HI DG ELECT PLUMB MECH
p p LICENSED CONTRACTOR'S DECLARATION
i 6 1 hereby affirm that I am licensed under provisions of Chapter 9(commencing Job Description
with Section 7000)of Division 3 of the Business and Professions Code,and my license is
n e in Imes force and effect i COM'L TI (13 5 0 SQ) SAGA .HAIR INTERIOR ONLY—NO
n z License Cl Lie.► '
Date Contractor e STRUCTURAL
i ARCHITECTS DECLARATION
,I II understand my plans shall be used a public records NO RE—ROOF r J&S QUALITY CONST RENEWED BUS
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t u Licensed Professional LICENSE.
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OWNER-BUILDER DECLARATION
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X I hereby arum that I am eumpt from the Contrwoes Lieensa Law for the
0 o following mason.(Section 70313,Business and Professions Code:Any city or county
F m Pi which requires a permit to construct,after,improve.demolish,or repair any stmctum
z y prior to its issuance,also requires the appliant for such permit to file a signed statement
s-< tha he is licensed pursuant to the provisions of the Conuahctoes License Law(Chapter 9 Sq.Ft.Floor Area Valuation
2 (commencing with Section 7000)of Division 3 of the Business and Professions Code)or
that he is exempt therefrom and the basis for the alleged exemption.Any violation of
Section 7031.5 by any applicant for a permit subjects the applicant to a coil penalty of APN Number Occupancy Type
not more than five hundred dollars(M)L
01.as owner of the property,or my employees with wages as their sole compensation, 36953999.2050
will do the work and the stnactum is not intended or offered for axle(Sec.70".Business
and Professions Code-The Contractors Lirrase Law does not apply to an owner of Required Inspections
property who bads or improves thereon,and who does such work himself or through bid
own employees,prided that such improvements ate not intended or offered for safe If,
however.the building or improvement is sold within one year of completion,the ownrr-
builder ,will have the burden of proving that he did not build or improve for purpose of
Zahn.).
❑L as owner of the property,am exclusively contracting with licensed contractors to
construct the project(Sea 7044.Business and Profession Code:)The Contraet°ls Li-
cense Law does not apply to the owner of property who builds or improves thereon,and.
who cenuaca for such projects with a contraetor(s)licensed pursuant to the Contractors
License Law.
❑1 are exempt under Sec. ,B&P C for this mason
owner Date
WORKERS COMPENSATION DECLARATION
I hereby affirm under penalty of perjury one of the following declarations
❑f hsve and wifl mainain a Certificate of Consent to self-insure for Workers Compen-
sation,as provided for by Section 3700 of the Labor Code,for the performance of the
worts for which this permit is Luoed.
❑I have and will maintain Workers Compensation lauuntrna,as required by Section
3700 of the Labor Code.for the performance of the work for which this permit is late.
My Workees mpensadon Insurance carrier and Polity number{�me: -
Canner: Polity No.: 239
CERTIFICATE OF EKEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(nib wct m need not be completed If the permit is for rent hundred dollars(i 100)
or lea)
I certify that in the perform&=of the work for which this permit Is issued,1 shall riot
employ any person in any manner so as to become subject to the Workers Compcstudon
Laws of California.Date
Applicant
NOTICE TO APPLICANT:If,alter making this Certificate of Exemption,you should
become subject to the Workes Compensation provisions of the Labor Code,you must
Z forthwith comply with such provisions or this penmit shall be deemed mvoked.
CONSTRUCTION LENDING AGENCY
►�+ I hereby affirm that there is a construction lending agency for the performance of
y! > the work for which tits permit is Issued(Sol-3097,Civ.C.)
:L) A Lenders Name
Z Lenders Address
:.J O I certify that I her read this application and sate that the above information is
GL ►•' coarser I agree to comply with all city and county ordinances and state laws mlaing to
Vbuilding construction,and hereby authorise representatives of this city to enter upon the
a above-mentioned property for irtspection purposes
(We)agree to save,indemnify and keep harmless the City of Cupertino sgainsf
HC/1 liabilities.judgments,teats and expemsea which may in any way accrue against said City ..
J in consequence of the granting of this permit. / cI
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT Issued by: Date u Z—d
SOU
u Re-roofs
Sigma o Applic n r Dale
H4tARDOUS MATERIALS DISCLOSURE Type of Roof
Will the applicant or future building occupant atom or handle hasadom material
w defined by the Cupertino Municipal Code,Chapter 9.12,and the Health and Safety
Code,Section 25532(a)7 All roofs shall be inspected prior to any roofing material being installed.
❑Yes No
Will thus applicant or future building uxzupaat use equipment or devices which If a roof is installed without first obtaining an inspection,I agree to remove
emit IwArdous air contaminants as defined by the Hay Area Air Quality Management all new materials for inspection.
District?
❑Yes No
I have read die hamrdots materials requimmens under Chapter&95 of the Califor-
nia Health&Safety Cade,Sections 25505.25533 and 25534.I understand that if the building
don net currently haw a tenant that it y responsibility to notify the occupant of the
requi rnet�;or � Fare or Signature of Applicant Date
Owner or authodz d agent Da,c All roof coverings to be Class'A"or better