04110025CITY OF CUPERTINOF�z`e
CONTRA CTORIINFORMATION
BUILDING DIVISION. PERMIT
BUILDING ADDRESS:
PERMIT NO.
CALIFORNIA POWER AND LIGHT
04110025
OWN R' It RAM : -
PERMIT ISSUE DATE
ONE:
SANITARY OC N0.
ARCHITECT/ENGINEER:
BUILDING PERMIT INFO
BLDG ELECT' PLUMB MECH
- -
t
0 0 0 0
j LICENSED CONTRACTOR'S DECLARATION
I hereby a'firm Nn 1 am licertcd under pr sons nl Clup¢r v (my he... is
z with SCI ierebya of Division aofd¢Buaundet for scssial 1xuptm9Couse.faidre license is
_ JOb De�CrIpI]On t) j� It p I� D
II\�\MVlt4/,Q_u,\\1
Z ittm ciAv" L r Lair —o
- '� Coeruwr
III�L�
iJlrpfl
Ii�PGRADE ELECT. SERVICE 200 AM JDJ _
— — -
yDam
AR HITELTS DECLAR
a I understand my plans shall W used as puhl ores
1.
" VX L —
NOV (] 2Ooi
II �I ll fA fy
LiecnSeJ Pmfcssinnel
S OWNER-BUILDER DEthe
Commenter
E I bemhy'affirm that I am exempt from the Cnnvonors License Law for the
D III'�/1111 Illll7
� � �
following reason. (Section 7031.5. Business and Profesdon" Code: Any City or county
- 1/l/v�'V
Z which requires a permit to construct, alter, improve. demolish, or repair any mmchou
IIIII11lk\\\IfJIl
^ Poor it) its issuance. also resiins the applicant for such permil to file a signed statement
License Low (Chapter 9
Sq. Ft. Floor Area
Value
Cthat he is licensed pursuant to the provimorsofNcContrecmri
$ (commencing with Section 7")of Division 3 of the Business and Professions Code)or
_ that be u exempt therefrom and IW besillor the alleged exemption. My violation of
��.ptst �..vay�e
3 1%73 b1816 7� 0
Occupancy Type -
Section 7031.5 by any applicant for a prosit subject the applicant In a civil penalty of
not mart Nan five hundred dollars ISM
• 11
I,ssownu of the propmy. ar my cmployus with wegu sstheir sale mmpensauon,
'
Required Inspections
will do Ne work ved Ne swcture is not intended m offered fallen, ScC.7os4, Bathhouses
Profession" Code: The Conmectars License Law does not apply m an owrur of
property who builds or improves thmaxon, end who doessuch work himself orthmugh his
awn employees. provided Nat such improvement m not intended orc ffered for sale. If,
however, the building or improvement is sold within one year of completion, the owner.
builder will have the burden of proving that he did not Wild or improve for purpose of
sale.).
1, as owner of the property, am exclusively contracting with licensed contractors to
Confirmthe project (Sec. 7004, Business and Professions Cocky The Conlracter's Li.
w does not apply men owner ofpropeny who build..,improves demon. and
naau for such pojeclswllh acomracuumm licensed puvuanim dm Conlnaois
law.
am eaempt under Sec. . B & P C fm this reason
Owner Data
..
WORKER'S COMPENSATION DECLARATION
1 hereby effirm under penalty of perjury, one of dee following declarations:
te of Conto self-hesum far Worker'sCompen-
' have and will maintain a Cenifatin
ion, os provided for by Section 3700 of the labor Code, for the performance of the
rk for which this permit is issued.
I have and will maintain Worker's Compensation Insurance, as required by Section
1M37M
-
of the Labor Code, for the eperformance of the work for which this permit is issued.
y Workeri Compensation lnsunnce carrier and Policy number ammcr:
Policy No.:
CERTIFICATE OF EXEMPTION FROM WORKERS'
a
COMPENSATION INSURANCE-
(The section faced not tecompleted if the permit is forones hundred dollars (5100)
,it less.)
1 certify than in the performance of the work for which this permit is issued, I ,shall not
..
iBapyTanncrsopv/u bleclmthe Workeri Compensation
Laws. Calif
Laws of Califom�a4llfv i
A m
N TO APP : IL after making this Certificate, of Exemption.dyou should
o
b orae suhj,en the worker's Compensation previsions of Ibe Labor Code, you must
Z' forthwith comply with such provisions or this permit shall be deemed revoked
CONSTRUCTION LENDING AGENCY
1 herebyhrm Net Nem is c3 lending agnry I'm Ne perunnaue of
> the work for which this permit is issued (Sec.07. Civ. C.)
lenders Names
tenders Address
7 1 emirs that 1 have mad this application and suu that the above information is
'
come,. I agree to comply with all city and county Ordinances and smm laws leading m
JWilding construction. and hereby authorise representatives of this city to enter upon the
almvcmenuoned pmpeny for inspection purposes.
We) agree to an. indemnify and keep harmless the City of Cupertino against
A liabilities,judgment. cost and extremes which may in any way acerae against said City
Z in consequence of the granting of this permit.
�+ APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT
/
Issued by:9 Date
SOURCE REGUI ATIONS.
Re-roofs
Type of Roof
111-!3—£
Sig Teo ionVContranor Date
l HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future building occupant atom or handle hanrdous material
as defined by the Cupertino Munici I Code. Chaplet 9.12Cand Ne Health and Safety
Cale. Section 35532(.)?
�Yn Na
All roofs shall be inspected prior to an roofing material being Installed.
P P Y g g
- If a roof is installed without first obtaining an inspection, I agree to remove
w,n Ne artificial Of ,ware Wilding occupafat use equipment or devices wm�n
mit brimodois air conmmlnint as defiled by the Bay Arta Air Quality Management
all new materials for inspection. `-
uin? /
D Ycs ESN
1 have read the Wvardous mamrials requirement under Chaper6.95 of Ne Calif.,
nice Health&SafetyCode. Sections 25505.25533 uWZ534. 1 understand thmifthe Wilding
tan not curse ly M1.0 a tome Not it Is my rcxpnnsihility w nntily IM1c o,cupent of Nc
reyuim which mum be met in issuance at a CenlEcme of Occupancy
Signature of Applicant Dale
All roof coverings to be Class "B" or better
Dow teed agent Dat,
spent