03120053 E
TY OF CUPERTINO COITT12AfiT(?Xq BUILDING DIVISION PERMIT �� . , �,,, ,-'W" ,
DING ADDRESS: R S FLOORING PERMIT NDO3120053
fER'S NAME: PCRMR L59OH DASH
ART CENT
Eo SANITARY OL NO.
I
ARCHITECTMNGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMBMECH
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OM p LICENSED CONTRACTOR'S DECLARATION Job Description
UM 1 hereby affirm that I am licensed under provisions of Chapter 9(commencing
with Suction 700(p)of Division 3 of the Busionm and Prafesaiuns Coca.mul my license is
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in fun force and effect. DEMO
5 FI Z License Class Lk.B
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S DamContractor
ARCHITECTS
DECLARATION
I undommnd my plans shall he usesed u public menrds
'WyU
.'�GLicensed hereby from
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OWNER-BUILDER DECLARATION O
Eng 2 I hereby.(firm that 11. aurin from the Contractor's Co License Lew for the
my
O O following moron.(Semon ttonstr Business and improve,
Professions Code:Any city or county -
$ which mquima a permit to cores the piles Improve,demolish.or mash any awment
t-Zi prionnits imuance,also requires the applicant for such permit filcasigned sminmonl
T�tFG that he is licensed pursuant m the provisions of the Convector' Law w(Chapter 9 Sq.Ft. Floor Area Vacua on
3$ (commencing with Section 7")of Division 3 of the Businossand Professions Code)or
3 that he Is exempt tMmfrom and the basis for the alleged exemption.Any violm0on of ,,W�WvT.
Section 7031.5 by any applicant for a permit subjects the applicant w a civil penalty of 3 3f'a eRA C.a aro 0 Occupancy Type
not more than Eve hundred dollars($500).
❑1.an owner of the property.army employees with wages m their sole compensation,
will do the work and Nestructure is not intended or offered for sale(Sm.Isms.BusinessRUlred Ins eCtl0OS
and Profession Cade:The Commerce,Liam law does not apply to an owner of q P
property who builds ser im prows thereon,and who does s uch work himself or through his
awn employees,provided thauuch improvements are,not intended ororreted toraal&If.
however.the building or improvement is sold within one year of compledon.the owner-
builder will have the burden of proving that h,did not Wild or improve for puggse of
sakJ.
C3 1,as owner of the property,am exclusively contemi ng with licensed contractors to
construct the project(Sec.7014.Business and Profoasimns Code:)The Contractor.Li-
cense law does not apply to an owner of property who Wilds or improves Merton,and
who convects for such pmjects with a conumetor(s)licensed pursuant in the ContracmYa
License Law. _
❑I am exempt under See. ^ ,B&P C for this moon
her �m Gs. / i�--� QQaO
WORKER'S COMP NSATION DEC048s1T1ON
I hereby affirm under penalty of perjury one of the following decorators:
1 haw andwillmeined aCeNfieamof Consentmsect-insumfar Wor e$Compen-
m%ion.m provided for by Secdon 3700 of the labor Code,for the Performance of the
work for which this permit is issued.
❑1 haw and will maintain Worker's Compensation Insurance,as sequined by Section
3700 of the labor Code,for the Performance of the work far which this permit is issued.
My Workers Compensation Insurance Gamier and Policy number see:
Carrier. Policy No.:
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(Thu section need not W completed if the permit is forma,hundmddollass($ign
nr lusts)
1 certify that in the performance of the work for which this permit u issued,l shall not
employ any person In any mannerm as to tocome subject to the Workers'Compensation
Laws of California.Dale
Applicant
NOTICE TO APPLICANT'If,after making this Certifiam of Exemption,you should
become subject to the Worker's Compensation previsions of one labor Code,you most
.J O funowith comply with such provisions or this Permit shall W dccmd revoked.
'�4 CONSTRUCTION LENDING AGENCY
(~ I Wreby affirm that there its construction lending agency for the Performance of
(Y,7 the work for which this Permit is issued(Sat.3091,Civ.C.)
WJ Q Lender's Nan,
.7 z Lender.Address
C)Q 1 certify that I have reed Ws application and sure that the above Informe0un is
D.P correct.1 agree to comply with all city and county on ince and state laws relating to
Q V building construction,and hereby authorismpresatsdve,ofthis city mcrier upon the
a above-mentioned properly for inspection purposes
(We)agree to sew,indemnify and keep harmleu the City of Cupertino against
liabilities,Judgments.costs and expenses which may in anyway accuse against mid City / > -
U 7 APPLICAeNT UNDERSTANDSf AnND WILL COMPLY WITH ALL NON-POINT Issued by: Date I 1/
r7 SOURCE REGULATIONS, /-Y 9
60
k Re-roofs
Signalu fApplicanUContractor e
HAZARDOUS MATERIALS DISCLOSURE Type of Roof
Will
@,applicant or future building Occupant more or handle ha us material
as defined by the Cupertino Municipal Cod,,Chapter 9.11,and the Health and Safety
de,Samar 25532(a)? All roofs shall be inspected prior to any roofing material being installed.
C]Yes FO
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
It hazardous air contaminants m defined by Ne Bay Area Air Quality Management all new materials for inspection.
District?
C]yes (1QNu
I have rad the hamolo.s romoialsrequirements under Chepicr&95 of tiro Califmr
ria Health&Safety CW..Sxdoa15505.15533and15534.Iundersund thaifdro Wilding
docs not currently haw a mann that It is my responsihiliry to noul'y No occupant of the
myuirements which must W met poor to imumcc of a Ccoifice of oecnPancy Signature of Applicant Date
° j All roof coverings to be Class"B"or better
tuner or amhorizcd egcm Datc