03030162CITY OF CUPERTINO
(1TC1]EXNtM{�'t
BUILDING DIVISION PERMIT
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PERMIT NO.
BUILDING ADDRESS:r
RYMIK DEVELOPMENT CORP
owm4AZMP HAZEL13HUUK DR
PERMIT ISS
7505 LEEDS AVE
PHON9yMfK
SANITARY OL NO.
(408)253-1424
ARCHITECTIENGINEER:
BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
LICENSED CONTRACrOR'S DECLARATION
Job Description
1 hereby affirm that 1 am licensed under provisions of Chapter 9 (commencing
with Section 000 or Division 3 of the HJps* pss and Professions Code, and myLlic�ens^e Is
in full force
NL " I�Ce'1S�i4t.4sil D 'f'1TC 7 /,
License Cl Li -
DEMO
Date tr tor_ it f.
ARCHMECrSfflCLARATION
1 crstand my s:hal as public records
'LiccrifitelihWas-knuff
OWNER -BUILDER DECATION
1 hereby affirm that 1 am exempt from the Contractor's License Law for the
following reason. (Section 7031.5, Business and Professions Code: Any city or county
which requires a permit to constmct. Aller, improve, demolish, or repair any structure
prior to its issuance, also requires the applicant for such permit to file a signed statement
that he Is licensed pursuant to the provisions of the contractor's License Law (Chapter 9
Sq. Ft. Floor Area Valuation
(commencing with Scclion 7000) of Division 3 of the Business and Professions Code) or
rj 000
that he is exempt therefrom and the basis for the alleged exemption. Any violation of
NIjrjl
Occupancy PrPber
Occll e
Section 7031.5 by any applicant for a penult subjects the applicant to a civil penalty of
not more than five hundred dollars (SSGo)
3 z zj 5'07 5 1. 0 0
❑ 1, as owner of the property, or my employees with wages as their sole compensation,
will do the work and the structure is not intended or offered for sale (Sec. 7044, Business
and Professions Cade The Contractors License Law dors not apply to an owner of
NO ASSIGNED PiqqI9tPdbM1e@ftS
property who builds or improves thercon, and who does such work himself or through his
own employees, provided that such improvements are not intended or oRemd for sale. If,
however, the building or Improvement Is sold within one year of completion, the owrer-
builder will have the burden of proving that he did not build or improve for purpose of
sale.).
❑ 1, as owner of the property, am exclusively contracting with licensed contractors to
construct the pmjcct (Sec. 7044, Business and Professions Code:) The Contractor's Li-
cense Law does not apply to an owner of property who builds or improves thereon, and ,
who contracts for such pmjecs with a contracmr(s) licensed pursuant to the Contractors
License Law. ,
❑ 1 am exempt under Sea , B & P C for this mason
Owner Date
WORKER'S COMPENSATION DECLARATION
I hereby affirm under penalty of perjury one of the following declarations
❑ 1 have and will maintain 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
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 ttnywgrk for which this permit is issued.
May Compeion Insuranceariaj+MMiicy um!
oW,oftrs
CdroEr: 1 s t'C ✓`� V s—GF�mlicy
V CERTIFICATE OF EXEMPnON FROM WORKERS'
COMPENSATION INSURANCE
• (nds section recd not be completed If the permit is for one hundred dollars (5100)
or las)
1 certify that In the performance of the work for which this permit is issued, 1 shall not
employ any person in any manncrso as to become subject to the Workers' Compensation
Laws of CAlifnrnia Date
Applicant
NOTICE TO APPLICANT: If, after making this Certificate of Exemption, you should
become subject to the Worker's Compensation provisions of the Labor Code, you must
' forthwith comply with such provisions or this permit shall be deemed revoked.
' CONSTRUCTION LENDING AGENCY
+
I hereby affirm Nat there is a construction lending agency for the performance of
the work for which this permit Is issued (Sec. 3097, Civ. C.)
Lenders Name
Lender's Address
j 1 certify that I have read this application and state that the above information is
:
4 cored. 1 agree to comply with all city and county ordinances and state laws mladng to
building construction, and hereby authorise representatives of this city to enter upon the
Above-mentioned properly for inspection purposes
(We) agree to save, indemnify and keep harmless the City of Cupertino against
liabilitiea,judgmens, toss and expenses which may in any way accrue against said City
' in consequence of the granting of this pc '
a APPLICANT UND STAN AN L COMPLY WIT AL NON -POINT
Issued by: D to
REGU ONS.
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2
Re -roofs
Type of Roof
Sign urc of App ncan ntractorDate
HAZARDOUS MA S DISCLOZUR'
Will the applicant or future buildin cupant at urdous material
as defined by the Cupertino Municipal Code, Chapter 9. ,ealth and Safely
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code,yes y
Yes o
All roofs shall be inspected prior to any roofing material being installed.
If a roof is installed without first obtaining an inspection, I agree to remove
Will the applicant or future building occupant use equipment or devices which
emit harardous air contaminants as defined by the Bay Ara Air Quality Management
all new materials for inspection.
District?
Ifo
❑Yes
I have read the hazardous materials requirements under Chapter 6.95 of thc Califor-
nia Health & Sarcty Code, Sections 25505, 25533 and 75534.1 understand that if the building
does not currently have a tenant, that it is m esponsihilily to notify the occupant of the
rox)ubem tswhichm mclp' rloi �enraeeriftcateoroccup
Signature of Applicant Date
qihl 3
All roof coverings to be Class "B° or better
O
t c. authorized Date