04110168 CITY OF CUPERTINO
BUILDING DIVISION PERMIT
CONTRACTQRINF®RMATIONa; - ---- -BUILDING ADDRESS: NIACKEYhCONSTRUCTION PERMIT No 04110168
OWNER'S NAME: PERMIT ISSUE DATE
SABA
E:
SANITARY ift1.NO.
ARCHITECT/ENGINEER: BUILDING PERMIT INFO
-- BLDG ELECT PLUMB MECH
aa0c LICENSED CONTRACTOR'S DECLARATION Job Description
w❑ I WreAy (firm that L am licensed under provisions Chapter 9(commencing
iW with Secuan] c fD,,iuon3of thy,. .. apron ns Code.and my,ecru is
n<e. in full forte
;°y_ a«n cel 2 Lie.g 514o93i REVISION- -IN HOUSE USE ONLY
,s Data
`` ARCHnECTSoc` �n rr t NO NEW. PERMIT ISSUED ORIG. #04100171
fon0.9kthnJ my plana shall be used as public
°au
3 0�; Licensed Professional
OWNER-BUILDER DECLARATION
Coa oto
I I hereby aRrm that I em exempt from the Contractors License Lew far the
00 fallowing reason.(Section](B I3.Buvincss and Professions Code:Any city of county
m 9 which nquirei a Permit to c misuuct,alter.improve,demolish,or repair any structure
prior to in issuutec,also requites the applicant forsuch permit to Glc a signed comment
F?G
that he u located pursuant ata provisions of the Contractor's Limns,Law(Chapter 9 Sq.FL Floor Area Valuation
$39
sercF (commencing with Section]OBO)M Division 3 of the Busints and Pofessinns Coac)or
WO that M is intent theafmm and the buss for the alleged exemption.Any violation of
notoose dtao five huMppiies l farrs a OO).it subjects Nc applicant to a civil Penalty of APN Number Occupancy Type
❑I,uowner of the pmpeny,mmy employmwith wagcsu Heir tele compeatadon, 35606022 . 00
will da am wad and the swmure is nosimandedaroffered forsala IS".7W.Bioau
and Professions Code:The Contractors Licaate Law does not apply to an owar of Required Inspections
property who builds ar i mProws thereon,and who dao such work himself or through his
own cmplo,ma.provided that such improvements are notinMMrd aro@red for We.If.
however,the building or improvement is said within ane yeu of completion,the owner
builder will have the burden of proving that be,did not Wild or improve for purpose of - -
tile.).
Q 1,as Owner of the property,am exclusively contracting with licensed contracmn in _
construct the project(Sec.o an Owner
and property
who
Code:i pr Cantfmmrs nd
come law dao not je es owner o(proPeny who Wilds or improves Connia.and.
who convects for such projects with a contractor(s)located pursuant w dM Cantnnori
License Lin-
0'..
aw.❑lam cacmPt undo Sec. .B&PCfor this won
wnar Date
WORKERS COMPENSATION DECLARATION
1 hcrchy affirm under penalty of perjury as of the following declarations:
haw and will maintain a Certificate of Consent In self-insure for Workers Compca-
ns provided far by Section POO of be labor Code.far rep porfomuae of the
work for which this Permit is L6aQ
Q I have and will maintain Workers Compensation Ir surance,u required by Section
3]OO of the Labor Code,for the performance of the work for which this Permit is issued.
Mr_war sCamPeatauan latunnc cartim and Policy number are:
Carrie/ f -'At Policy No.:OSc'"reLOGL j_
EREXEMPTION MOM
M
W
COMPENSATIONINS N
(Thismctionnccdnothccomplcwdifthepermitis oronchundmddollan(SIIX)
or less)
1 certify that in the performance,of me work for which this Permit is issued.)shall not
employ any Perron in any manner an u in became subject to be WOrycn'Compeatxtion
Laws Of California.Data
Applicant
NOTICE TO APPLICANT:If,after making this Certificate of Emmption.you should
become subject in the Workars Compensation Provisions of thc labor Code,you seta
.,O forthwith comply with such provisions or this Permit shall he damcd rowked.
Zvj CONSTRUCTION LENDING AGENCY
(-. I hereby aRims that them its construction lending agency for the perforant of
r! the walk fur which this permit is issued(Sec.3097,Civ.C.)
a tender:Name
=z Under's Addw
U Q I modify dart I have mad this application and rote that tW above inforauun is
Iy F
correem.I agra,m comply with all city and county oNinam:o re and sum laws relating to
0 U building constructions and hereby authame repraentildwu of this city to enter upon me
above-ntarommd property for inspection purposes *110—
HAZARDOUS
(We)agree h taw,indemnify and keep harmless Ibe City of Cupcnino against liabilities,judgments,cones and cabooses which may in any way accrue against mid Cityz A PLICA T of DERSTAN of suis Permit.APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT Issued by: DatSOUR REGUy�TIONS.
��a Re-roofs
use of ApplicanUConuxta Date MATERIALS DISCLIICM Type of Roof
Will the applicant tar future building acupanutom or Mndk haaardau metrial
as deOad by the Cupertino Municipal Cade.Cbmair 9.12,and the Health and Safety
Code. yea 25532(a)?
0ss�� All roofs shall be inspected prior to any roofing material being installed.
Yes pl Nu
Will Ne,applicant or-future building acupam um cyvi,room or devices which If a roof is installed without first obtaining an inspection,I agree to remove
t harardoua air contaminants Is JCfimil by tM Bay Area Air Quality Management all new materials for inspection.
la?
Q Yea
1 have real the WaaNaus maurialsmquircmcros under Chapmrb.95 of the Califor
ma"Won k Safety Code,Secuors 25505.25533 and 25534.1 undenmnd thti Wilding
does rut currently haw a Mount,that it is my responsibility t notify the occupant of the
rcyuirtmcn kh m et poor t issuance of a CmtifcaM of Oce pan
`�r� Signature of Applicant Date
ner or aumariped age _ 3GDm, All roof coverings to be Class "B"or better