04080083 (2) CITY OF CUPERTINO
BUILDING DIVISION PERMIT CONTRACT�ORwyTNFORMATION�
BUILDING ADDRESS: PERMIT NO.
SUITABLE CONSTRUCTION 04080083
1601 TA.MRS TOWN IDR
OWNER'S NAME: PERMIT LSUE DATE
SANITARY OL N0.
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ARCHITECT/ENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
u00 LICENSED CONiRACTOR'SDECLARATION Job Description
ZC I Wish,effort that 1 am IiavN under provisions of Chapter 9(ctimmcming
<U with Sceu ]OOUI of Division f�he Burin tl I'miessind CmA.mnd my licens,is
;fa"fa REVISION--DRAIN
r G^m"di° NO NEW PERMIT ISSUED/ORIG. #03070133
Z A prF SOEcu
I unticnanJ my plat1xefiell k used u pia meds
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=a� LkansedPodfeaton.l e
OWNER-BUILDER DECLARATION
1 kraso .(Sero o n 1 n. exempt from dee Conine Cas License LAW o far the `'�
p o whichfollowing mason.(Section]1131.5.Business and P e,dicrues h.Or Any city m county
X m� which nyuifet a Permit 10 CoesWCl,eller.ImprnvC,dcmnirh,Or repair any alNctum
=Zj,
He,ini.issuance.at.mq.ims the applicant for such permit to Ola a signal stammmt
FSC NalhcisliccnscdPursuammthaPlavisionsnfd¢Canlrwmr'sIJ¢vclsw(Chap¢r9 Sq. Ft. Floor Area �(7, luation
rot• (commcmingwith section 7")of Division 3offeeeBusiness and ProfessionsCodc)or ��
y $
on,W is exempt thcmfmm and the India for the alleged exemption.My violation of
Section 7031.3 by my applicant for a permit objects Nc applicant to a civil penalty of APN Number OeeupanType
not more Nan Evc hundred dellen($500).
❑I,ndowner of 4M1e ProPmy,mmy employees with mgesu their ole compensation,
will do dee work and died strocmte is maimmuded mothered for side 70A4,Business 6610098 . 00 Required Inspections
and Professwe"Code:The Commodities License Law does not apply to an owmr of q P
progeny who builds or improves thexam.and who does such work himself m through his
Own employees,provided thatsuch improvements K not intended moResed for aide.IL
however,the building or improvement is old widen am year of compledon.Ne owner- .
builder will have the,burden of proving than he did not build or improve for POTmc of
sale.).
D 1,As come of Ik company,am exclusively conmating with licensed mmromrs to
construct the pmjca(Sec.7044.Bminea and Professions Code:)The Conmacmrs V.
came Law docs non apply man owner of pmpcny who Wilds Of improves Oeemon,and
who concocts for such pmjecu with a conuactm(s)licensed pursuant to Ik Conmotoes
LKCM1Y La .
D l am exempt under Sea .B&PC for Nu loon
Owner Data
WORKERS COMPENSATION DECLARATION
1 hcicby affirm under porosity of peljuO om Of dee fallowing declaram orm
have and will maintain a Cenificam of Consent m selGinmee far Workers Compen-
sation,as provided for Section
by 37M of the Labor Code,for the perfarmand,of the
work im
for which this permit is issued.
1 have and will maain Workers CompemNon I....nd Ieyuiced by Section
3700 of Ne LaWn Codc.for the pcfform once of the work for which this permit is eased.
F44COEMPE�Ag�ON
r Policy numk ass::
(icy No.:
ION FRO RK S'
N INSURANCE
' (This stolon nectl notkcomplemJiflbe permit is roromhundrod dollen(E 1011)
m leu)
1 certify that in the performance of the work for which Nis permit is issued,l shall not
employ any Peron in any mannero As,In become objCCI10 the workeri Compmeadon
Lawa of California.Dam
Applicant
NOTICE TO APPLICANT:If,after making this Cenificale of Exemption,you should
become aubjest in the Wo&els Compensation provisions of the labor Code,you mum
., rOMwlth comply with soh provisions or this permit shall k deemed mvel ed.
z 0 CONSTRUCTION LENDING AGENCY
[.. I kmby nRW dmf then is•eonsuuctinn Icndinpgcney or the Ferber inanto tar
tY.ti the walk fur which thts permit Is issued(Sec.3097.Civ.C.)
111A l<ndcra Name
6. teendeh Address
V 1 sentry than 1 have mad this application and sum that the above information is
4. P correct.l agree be comply with all city and county ordinames and sum laws mlating m
O V building construction.and hereby auihofire tepreieniatiws of this city In enter upon the
x[17 shove-mcn ionced pmpody rot inspection purposes
O. (We)agree maw,indemnify Alia keep harmless the City of CyPenmo against
E' N liabilities,judgments,costs and expemes which may in any way¢crud,against aid City
V Z in causeimeme of the granting of this Permit '
'—' APPLICANT UN NDS AND W L COMP H ALL NON- INT Issued by: Date
S UR ATIONS. �1
Re-roofs
,,I&d.fAppli,ardrCmdUmmr D
RE Type Of ROOF
HAZARDOUS MATERIALS DISCLOSU
Will the applicant or future building Occupant more or"out haerolous material
as def ncd by site Cupenino Municipal Code.Chapter 9.12.and the Health and Safety
Cade.section 25532(a)? All roofs shall be inspected prior to any roofing material being installed.
❑Yes
pWill 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
I hazardous air contaminants as defined by the Bay Area Air Quality Managemem all new materials for inspection.
i.iet7
Dy"
IhaveteadtW idcusm iialsmquimmenuundcr Chapter S.Fuln, llfof-
maHcalth&S,byCcdc.SccumdM501.25533am1255M.I undo irthc Wilding
does not etmendy haw I,Net It hi ibility m de,mcupanl of We
m immen mnmkmetprior up
s^° nature of Applicant Date
tar authorised agent ,m / All roof coverings to be Class"B"or better