09050119 CITY OF CUPERTINO _ t a s sea
BUILDING DIVISION PERNIIT � ( ��� �C�
BUILDING ADDRESS: PERMIT NO.
10260 BUBB RD rT.TMATR
OWNER' PERMIT LSSUE DATE
PHONE:
A CONTROL NO.
408) 861-0786
ARCHrrECT/ENGiNEER: BUILDING PERMrr INFO
BLDG ELECT PLUMB MECH
a o 0 0
00 LICENSED CONTRACTOR'S DECLARATION
i.11 hereby affirm that I am licensed under provisions of Chapter 9(commencing Job Description
-O with Section 7000)of Division 3 of the Business and Professions Code.and my license is
in full force and effect. .:Is-39' COMMERCIAL REMOVE AND REPLACE 16 ROOFTOP PACKAGE
3 License Class Lie.0 A/C UNIT S
3 Date Contractor
.t 1 hereby affirm that 1 am exempt from the Contractor's License Law for the
❑O following reason.(Section 7031.5.Business and Professions Code:Any city or county
$ which requires a permit to construct.alter,Improve,demolish,or repair any structure
y prior to is issuance,also requires the applicant for such permit to file a signed statement
3 C that be is licensed pursuant to the provisions of the Contractors License Law(Chapter 9 Sq.Ft.Floor Area Valuation
g$ (commencing with Section 70M)of Division 3 of the Business and Professions Code)or
yo that he is wcempt thuefrom and the basis for the Wlq d exemption Any vlolation of
8100000
Section 7031 J by any applicant for a permit subjects the applicant to a civil penalty of APN Number Occupancy Type
not more than rhn hundred dollars(5500)
C]L as owner of the property,or my employees with wages as their sate compenudon. 35720021 . 02
will do the work and the structure is not intended or offered for sale(Sec.7D44,Business
and Professions coda The Contractors License Law does not apply to an owner of Required Inspections
property who builds or improves tbereon,and who does such wart himself or through his
own employees,provided that such improvements are not intended or offered for ale.If,
however,the building or improvement is sold within one yew of completim the owner.
builder will have the burden of proving that he did not build or Improve for purpose of
ale.).
❑L as owner of the property,am exclusively contracting with licensed contractors to
corstruct the project(Sec.7044,Business and Professions Code:)The Contractors Ll-
cerue Law does mot apply to an owner of property who builds of improves therearr,and
who contracts for such projects with a contractor(s)ficensed pursuant to the Contractors
License Law.
❑I am exempt under Sec. .B&P C for this mason
Owner Date
WORKER'S COMPENSATION DECLARATION
I hereby affirm tinder penalty of perjury one of the following declarations
❑I have and will maintain a Certificate of Consent to self-insure for WorkersCompcn-
sation,is 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 insurance,as required by Section
3700 of the Labor Code,for the performance of the work for which this permit is issued-
My Workers Compensation In-
carrier and Po her are:
Carrier. Sd�AV4!LKACID,14 tcyNo,:I.1'&um//-7L�F 7i
CERTIFICATE OF EXFA4PTTON FROI4ORK�
COMPENSATION INSURANCE
(17+1s section need not be completed if the permit Is for one hundred dollars($100)
or less)
I certify 0st ire the perfo nee of the work for which this permit is issued I shall not
employ any person in
you should
become subject to the Workers Compensation provisions of the Libor Code,you must
❑ z forthwith comply with such provisions or this permit shall be deemed revoked.
z CONSTRUCTION LENDING AGENCY
PrA I hereby affirm that them is a consuuetinn lending agency for the performance of
iX > the work for which this permit is issued(Sec.3097,Civ.C.)
W Q Lenders Name
Lenders Address
U 0 i certify that I have read this application and sure that the above information is
fy correct.I agree to comply with all city and county ordinances and state in"reusing to
0 SV' building construction,and hereby authorize representative of this city to enter upon the
W above-mentioned property for inspection purposes
LL (We)agree to
Re-roofs
Signature of Applicant/Con r Date
HAZARDibUS MATERIALS DISCLOSURE Type of Roof
Will the appleant or futi m building occupant store or handle hazardous material
as defined by the Cupertino Munictpar ode.Cbapter 9.12.and the Health and Safety
Code.Beetles 25532(a)7 All roofs shall be inspected prior to any roofing material being installed.
C:]Yes o
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
emit hazardous air contaminants as xfrned by the Bay Area Air Quality Managemcni all new materials for inspection.
District?
❑Yes 0<0
i bout read the materials temcntt under Chapter 6.95 of cite Califon.
niaHealth&
tear Signature of Applicant Date
Oanner or autho' agent etc
'O All roof coverings to be Class'J¢"or better