07100178 CIT�' OF CUPERTINO ° '
�C,d)�V1�'�G�C)R I���RN�AT�O�•
BUILDING DIVISION PERMIT , . :
,. _
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— PERMIT NO.
BUiLDING ADDRESS:
A
�R'S NAME: INC
S CONTROL NO.
Pi-ION :
i
BUILDINO PERMIT INFO
ARCHiTECT/ENGiNEER: BLDG EI.ECf PLUMB MECH
� 0 0 �
j � UCENSED CON7RAC7'OR'S DECLARATION JOU DeSCflpt10A
� E:. I hcrcby afGcm that 1 am liccnscd undcr provisions oC Chaptcr 9(commencing
:� with Scction 7000) of Di ''on 3 of �hc Busincss and Profcssions Codc, and my licensc is
' a in tull foree and cttec� ?,>'?) (.� 7 y CQ�I ' L `L' . I.� BLD 2 STORY
3 � �icensc Clus Lic. �
; p Datc � Conuaaor
,� A CHITECI'S DFLLARATION C!i S(1r1.K.t
° -a 1 undcrstand my plans shall bc uscd as pubiic rccords
��
U
� Liccnscd Pmfcssional
� a OWNER-BUILDER DECLARATION
��
1 hcrcby alTirm that 1 am cxcmp� frum ttic Conuactors Liccnsc Law for thc
j O following rcason. (Scction 7031.5, Busincss and Profccsiont Codc: Any cily or county
;� which rcquires a pertnit to cnnswc4 a��r, impmvc, dcmolish, or repair any structure
; y N, pnor to iLt issuancc, also �r.quircs lhc applican� forsuch permit to 61c a signcd stalcmcm �' Ft. Floor Area Valuation
� a �y� nc is liccnscd pursuant to thc pmvisions of thc Contractar's Liccnsc Law (Chap�cr 9 •'
-$ (commencing wi�h Scction 7000) of Division 3 n( thc Busincss and Profcssions Code) or
�.. that he is ezempt the�efrom and the basis for �e allcgcd ezemption. Any violation o[
SecGon 7031.5 by any appticant for a pWmit subjects ihe applicant �o a civil pcnalty ot APN Number eeupaney Type
not more than five hundred dollars (5500).
❑ I, as owncr oC ttie property, or my employces with wages xs ihe'v solc compensaGon, 316 0 6 0 4�. 0 2
wiRdothework.andihestcuctumisnotintendcdorof[eredforsale(Sec. Required Inspections
end Pro(essions Code: The Conuaetor's License Law does not apply w an owner o(
propeny who builds or improves thercon, and who does such work himself or thmugh his
owo employces, provided that such improvemen�s are not iNended or o[fered for sala lf.
howevcr, the building or improvement is sold within one year of compledon, �he owner-
builder wilt have the burden oC proving �hat he did not build or improvc tor purpose of
sak.).
❑ I, as awner of Uie property. am exclusively conuacting wi�h licensed convactnrs to
construct �he projett (Sec. 7044. Business and Professions Code:) 7t�e Coovactor's Li-
ccnsc Law docs not apply to an owner of propeny who builds or improves �hueon, and ,
who conuac�s for such projects with a contractoKs) licensed pursuant to the Convactors
License Law.
I� I am ezempt under See , B& P C for this rcason
u Daie
WORKER'S COMPENSAT'!ON DECLARAI'ION
I hercby affirm under penalty of perjury onc of �fu (oilowing declarations:
❑! hsve and will maintain a Ceni6cate ot Consent to ulf-insure for Worlcer's Compen-
sation, u provided for by Secdon 3700 oC U�e Labor Code. (or ihe pedormance of the
work [or which Ihis pertnit is issucd.
❑ I havc and will maintain Workcrs Compensadon lnsurana, as requircd by Scction .
3700 oC the Labor Codc, Cor thc pcdormancc o( �he worlc for which �his pecmit is issued.
My Workers Compe Insurance carticr and Policy number am:
Cartier. 1 1 Pi�fG l4 S✓f (1 �✓) Polity No.: � 3� 2 Z Z-��
CE IFICA OF EXEMP770N FROM WORKERS'
COMPENSA7'lON INSURANCE
(ihis uction need not bc comple�ed if tAe permit is for onc hundred dollars (E100)
nr Icss.)
1 ceni(y �hxi in thc performance af thc work for which this permit is issucd. [ shall not
employ any person in any manncr so as �o become subject to the Workcrs' Compcnsation
Laws ot Califomia. Datc
Applicant
NOTICE TO APPLICAM: If, af�cr making this CcniCca�e of Exemption, you should
become subject to the Worker's Compensation provisions of Ihe Labor Code, you must
� O forthwilh comply with such provisions or this pecmit shall be dcemed �evoked.
7
"" CONSTRUCTION LENDING AGENCY
�.�-. I hcreby affirtn ihat thcre is a conswction tending agcircy Cor thc performancc of
�� thc work for which ihis pertnit is iuucd (Scc. 3097, Civ. C.) ,
1 Q L.endcr's Name
� L.cnder's Address
�z
) � ! ceniCy �ha� 1 have rcad �his applieation and s�ate iha� ihe above infortnauun is
� cortcc� I agrce to comply with all city and county ordinances and sute laws reladng w
� U building consuuction, and hcrcby authori�t rcprescntativcs of this ci�y to cntcr u�n �hc
� W abovc-mcnaoncd property for inspcctioa purposcs
� a (Wc) agree to save, indcmnify and keep harmless thc City of Cupertino agains�
�� liabiliues, judgmcnts, costs and ezpcnscs which may in any way accrue against said City /`
),'� in consequence oC Urc granting of Ihis pertniG Date jC/� � L�/ -✓L
� APP UNDERSTANDS AND W COMPLY WITH ALL NON-POINT Issued by:
SO CE GULATIONS.
.�K�- �b 2-�f a Re-roofs �
Signature of ApplicanVContrac or De� T of R�of
HAZARDOUS MATER1ALS DISCLOSURE }��
Will the applicant or futurc building occupant storc or handlc ha•rardous matcrial
dcfined by the Cupertino Mumcipal Codc. Chapicr 9.12, and thc Hcal�h and Safety
j�. Scction 25532(a)? All roofs :,hall be inspected prior to any roofing material being installed.
�y� �No
wIl thc applicant or future building accupant usc cyuipmcnl or dcvices which
If a roof i:, installed without first obtaining an inspection, I agree to remove
cmit harardous air conuminants as dcfincd Ay the Bay Arca Air Quality Managcment all new m iterials for inspecrion.
District? .�f
❑Ycs �Nu
1 havc rcad ihe ha�ardous maicrials requircmcn�s undcr Chaptcr6.95 of ihc Cali[or- � / �b`2 �{�
nia Hcalih & Safc�y Codc. Sections 25505, 25533 antJ 25534.1 undcrstand �haz if ihc building f e�� . �
docs not c havc a tcnan4 �< i� y respoos9bility m no6fy thc occupant of �hc
rcyuirc �n� �mus � uanceo� [�i fca�cotpccuj�ancy�7 Signature of Applicant Date
/1 � ���� `� ° All roof coverings to be Class "B" or better
Owncr or au�hori�td agcnt D��