08030073CITY OF CUPERTINOBUILDING
DIVISION PERMIT
CCINTRA.G'�4R.Ii�f3it1V,[A'T"Ifl"':
BmLpY)�G�t 13ELKNAP DR
y
TBD - TO BE DETERMINED
PERMIT
08030073
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SANITARY NO. CONTROL NO.
ARCHITECT/ENGINEER:
ADD IBDRM, 1/2 BLDG BUILDING PERMIT INF
MECH
Fdffifi 0 0 0 0
LICENSED CONTRACTOR'S DECLARATION
Chapter
--"'^-^- �-•_^^•• -------Job Description
m
I harm that ati em limvcd under provisions or r9 (mmcncing
with Section 700M of Division 3 ofthc Business and Professions Code, and my license is
in full force and client.
Liceno Clsss Lie, Is
Dam Conuacter
ARCHITECT'S DECLARATION
I understand my plans shall W used an public records
Licensed Professional
OWNER-BUILDER DECLARATION
I Wreby M. Not I nm exempt from Ne Cmu erne. U.... Law far the
following mason. (Section 703 LS, Business and Pofessiov Code: Any city m county
which requires a permit to cnnmme, alter, improve, demolish, or repair any strunum
! prior bits rename, arm mquirex tW applumt for such permit to file a signed statement
thet he is liceemd pursuant to the previsions of db Contractor's Umnse, Law (Chapter 9
Sq. Ft. Floor Area Valuation
(commencing with Section )000) of Division 3 of the Business and Profession Code) or
that m it exempt thenefmm and the basis few the alleged esnmplim. Any violation of
Section ?031.5 by airy applicant ler. permit subjecs Ute applicant to v civil penalty of
AFN Number
Occupancy e
P TYP
nm moue man five hundred dallasa (SSOD).
y
❑ I, u owner of tix Pmpm4Y, m my emplayw wire wage u tim'vole compensstion.
will do the work, and the structure is net intended or offered for sale (Sec. 1014, Business
and Pofnssions Cade: The CmWasto's License Law does act apply to o owner of
_ Required Inspections
property who Wilds orimproves doommand who dm3mch work himselfor though his
own employees, provided that such improvements are mtimarded aroRered fmsale, R.
man,m,, the Wilding Or impmvament is old within ane your of cmnFletion. the owner.
Wilder will have the burden of proving that he did not WiM or improve for purpose of
sale.). -
rgj'l. m owns of the property. w exclusively contracting wire licensed commeton to
carmuet the project (Sec. 7044. Business and Professions Crede:) The GomrXbra U.
come Law does not apply as an owner of property who Wilds or impom daemon, and
who contracts for such prejecle with a conVHctor(s) licensed pumaam to the ConVMtori
eve Law.
amesemptundu See ,Bh PCfmthismason
or ��-��. Dam
WORKER'S OMPENS' ATION DECLARATION
1 hereby aPvm under poetry of perjury ane of the following dmlerations:
❑ I lai. and will amounts Cor ifiace rcmanum au self-ins. fm Wad er'seom,not
sation, an provided for by Section 37W or the Iabm Code. for she perfarmamx of the
wads for which this permit is issued.
❑ 1 haw and will maintain Work e, Cmmperua kso I... as required by SmOm
37W of the Ubar Code, for the podmo aria of the were, forwhich this permit u issued.
My Worker's Compensation lnsurm a artier and Policy number am:
Cartier. Policy Nm.:
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
Mas sectan nod trothecomphned if the permitis formas hundred dallan ($100)
or leu)
1 anify that in the performance of the work far which this Permit is issued. l shell not
employ any person in my manmr as as bb subject to the Workers 'Compensation
-
Uw, of Califom a. Dale m.3 / r A h �... O
Applicant
NOTICE TO AP C `after making mu Ceniaate o Exemption, you should
became subject th the Worker's Compcvation provisions of the Labor Cade. You muse
forthwith comply with men provisions or this Permit shall be domed remkcd.
CONSTRUCTION LENDING AGENCY
1 hereby affirm mat there is a cameraman lending spoof for the Mrformamx of
On work for which this Permit Is named (Sm. 3091, Civ, C.)
Lcndofs Name
lcm1ces Address
1 modify that 1 haw mad this application and sure this the etas information in
cermm. I agree b comply wire all city and county am!., and sure laws relating b
building construction, end hereby mthmriw mpremnomm of this city to enter upon the
arrow-mentioned property for inspection purposes
t as the City o(Cupertino dents agunsr
(We) agree to pass indemnify and keep may
and ex penseswhich they in oy way ecuue Indent said City
incoiGequenc of the
of the granting of this permit
A
APPLICANT
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT
S R EGULATIONS.
Issued by: Date / orf---
7
��ls �" $
Re-roofs
Stg.a. of AppliargCanuxor Date
HAZARDOUS MATERIALS DISCLOSURE
Type of Roof
Will the applicant or future Wilding mcupotsam or handle Incautious material
—/
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deflood by On Cupam. Municipal Code. Chapter 9.12, sand the Health and Safety
/
we, Section 25532(.)1
❑ Yes WINO
All roofs shall be inspected prior to any roofing material being installed.
Will the applicant or future Wilding occupant use equipment m dcvi= which
If a roof is installed without first obtaining an inspection, I agree to remove
Iml�nv air contaminants as defined by me Bay Area Air Quality Management
all new materials for inspection.
.it
De
0Yes QNo
1 havemalthehesardwsme505.5533re enuunder Chapar6.aifso
nixs naith&Safety Cale, Null dm Wilding
Wilding
5533aW 25534ty
leasom. me is
dao nal currently hew a Tenant Nat it u my mapmvibility b notify de mempot of the
toraf, t
gwre� w' mxmelp� o �ar.cnrateJaaI VP
Signature of Applicant Date
_ All roof coverings to be Class"j?." or better
Owner or mthonucd agent Date - -