08010175 CITY OFCUPERTINO /� kewwaa{ ;r€ao
BUILDING DIVISION PERT
BUIlaTlCsDpgEsLAURETTA DR TBD — TO BE DETERMINED P08010175
NER'S NAME: PERMIT ISUH DAIS
SANITARY NO. CONTROL NO.
ARCHI ECTIFNGiNEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
goo LICENSED CONTRACIGR'S DECLARATION
e V I hereby affirm Wt 1 am licensed under provisions of Chapter 9(commencing Job Description
ire with Section 700M of Division 3 of the Business and Professions Code,and my licamse I- ADD 713 SQFT,.GST BED,BTH& MEDIA RM
^=w in full force and effect. -
j Z Licence Class Lie.at
Dam Contractor
ARCHITECTS DECLARATION
I understand my plans shall be used as public records
311
yG Licensed Professional
7 OWNER-BUILDER BUILDERO the Contractor's
9 I hereby.(firm mot 11. eumpt from the consC License Law for the
p O following reason.permit
t SDI.q Business and Perfusions Calc:Any city or county
e
$ which its i su•permit m construct,applialies.cant
improve,do Permit
E or e a sig any structure
_Z priors itsiensedpalso requires theapplicant ry ach permit mccasigned Chimes
< that hais licensed purwur to the provisions of the ConuxmYa Lmensahaw(Cbapmr9 Sq.Ft.Floor Area Valuation
y�0 (cat he I, see pt Sufrom and the
Division r of de Busalleged
rum androo Pnoresson.Any
Codic)lmun of $150000
3
that io u exempt thac(mm and or bub for the alleged pplICUon.Any l Penalty
of
.1
section 7031.5 five
any appBanl for a permit abKeu the appl'vant m•Civil penalty of Number Occupancy Type
net ream than Res hmnarcd dallus asaB) 3 2 6 5 5 0 0 7!��
1,uOwner of the Property.Or my employes with wges as doh sok compensation,
will W the work-and the stracmrc ts not mernaed or offered for maer(See.7044,Business
me Pmfeulam Cone:Tie Cenvacure,License law does WE appy m an awes of Required Inspections
properly who build,Or improves thereon.and who doessuch work himsefor through his
Own=play=,provided that such improvements are tmtinlended oroRemd fertile.IC
howem,the boildog or Improvement issold within ane Year of complmian,the owner-
builder will have the burden of proving that he did WE build us improve for purpose of
sale.).
(�,a Owner of the property,am o-cluively contracting with licensed contractors m
'eonstmct de project(See 7044,Business cod Phefudans Cede:)The Comment's Li-
cense Law dons not apply to an Owner of property who builds or impmm themer.and,
who convects for such pmjeca with a conuactar(s)licensed pursuant 0 the Commerce,
License law.
am eapin funder Sede,� ,B&PC for this moon
net Dam
WORKER'S MPENSATION DECLARATION
1 hereby allirm under penalty of perjury one of the fallowing declarations:
❑I hum and will maintain a Certificate of Covent m self-haver for Workdm Compere
sauon,as provided for by Section 3700 of de Labor Cade,fur the performance of the
work far which this permit u issued.
❑1 have and will maintain Warkeem Compensation Incomes,an required by Section '
3700 of the labor Code.for the Performance of site cork fvwhich this Permit is lusted. '
My Workers Compenadon bourses carrier and Policy number am:
Cartier. Policy NO:
CERTIFICATE OF EXEMPTION FROM WORKERS
COMPENSATION INSURANCE
flits section need mut be compleed if the pc uth is fame hundred tailors($100)
or mss)
I«airy dust in the Performance of the work for which this permit blamed.l shall WE
employ any person In any muncm4.;abed m the Workers'Compensation
lama of Califtroo.Data /'',-
Appil.,
NOTICE TO APPLJCANI`.If,after making this Certificate of Exemption,you should
become subject in the Worker's Campenation previsions of the labor Code,you must
vJ O forthwith comply with such pmvblo d m this Permit hall bo doomed revoked.
� VICONSTRUCTION LENDING AGENCY
Ihemhyafnrm that ft.tsacovuucdnn lending agency for the perfosmanee of
F6> the work for which this permit Is Issued(Sec.3197,Civ.C.) '
{s)Q lender's Name ,
O z 1<nder's Address
V O I certify that I have read this application and mum that the above information b ,
Iy H correct.l agora to comply with all city and county ordinances and suer laws miming in
0 V buildingconwuction,andherebyauduoriscmpruenutimorthilCityinenterupWde
[gl above-mentioned property for inspection purposes
d (We)agree to ase,indemnify and keep harmless the City of Cupertino against
H Iiabilidu,judgmcnWca4 sed which may In try way accrue,gaunt said City
U Z APPLLIC=Uri gMv DS AND"'LL COMPLY WITH ALL NON-POINT Issued by: Date �Zr
SOURCE
Da
HAZARDOUS MATERIALS DISCLOSURE Type of Roof
Will de applicant or future building ammputaom a handle haardaa mamsbl
as de0vd by the Cupertino Municipal Code.Chapter 9.13.and L e Health and Safety .
0 25532(a?25532(a?yes All roofs shall be inspected prior to any roofing material being installed.
❑Yu 10<
Will the applicator or future building ucovpant use equipment or devices which If a roof is installed without first obtaining an inspection,I agree to remove
EMIL havardna air contaminants as de0ned by the Bay Arca Air Quality Management all new materials for inspection.
District?
0 Yes
Ihavemadthe hvadousmae srequiremen"underChapter6.95oftheCalifor-
.iceHcslth&Safely Code, euauja565,35537 25534.IuMcrshvM mailthe dmilJing
den not
IsCertificate arOccupancy. Signature of Applicant Date
owner r amt .cam am All roof coverings to be Class'/¢"or better
v
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