03100209 CI'T'Y OF CUPERTINO ' ••
BUILDING DIVISION PERMIT �0NTRACTOMINFORMATION m`
BUILDING ADDRESS: rc PERMIT ND03100209
VER'S NAME: PERMIT ISSUE DATE
TONE: SANITARY NO. CONTROL NO.
ARCHITECT/ENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
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fop LICENSED CONTRACTOR S DECLARATION
"e-r 1 ncrroy affirm the I am ficerwa Indo,provisions of Chapter 9(cnmmenelag Job Description
SzW with Section 1018)u(Division 3 of the Busd Professions Coode,a re,license is
^toyin full fa eRcct. t�0
,qz L;een:eg�a° ue.a 2� ADD 470 SQ. FT. -
;�� DaCu r CONTRACTOR: M-TRAN CONSTRUCTION
A CHITECT LARATION
w ed a I understand my plans shall be used as public records
au
3 t"
Licensed Pmfcssinnal
O OWNER-BUILDER DECLARATION
<I 1 hereby affirm that 1 am cxcmpt from the Contractor's License Law for the
p o fallowing rcoson.(Section 7031.5.Business and Profesomes Calc:Any city lir county
v,m which.,arm,a peril Io construct,alter,improve,demolish,or repoir say machine
pdorto iuissmncc.alworcLaires the applicant for such Permit to Glc a signed statement
f c that he is licensed pursuant to the PmvisionsnfNcContractor's Licence Law(Chapter 9 Sq. Ft. Floor Area ValuO§6400
yI (commencing with Section 7000)of Division 3 of the Business and Professions Code)or '
Nal he is cxcmpt therefrom and the basis for the alleged exemption.Any violation of
Section'1831.5 by any applicant for a Peril subjects the applicant to a civil Penalty of APN Number Occupancy Type
not mem than five hundred delta.(5580). Pane Y YP
01,as owner of the property.or my employees with wages ae Ncirnule compensation, 37538008 . 00
will do Ne work.and the awcture is not intended or offered for sale(See.7DW,Business
and Professions Code:The Contractor's License Law does not apply to an owner of Required Inspections
property who builds or improves Boemon,and who does such work himself or Borough his
own employees,provided that such improvements an,not intended or offered for sale.IL
however.the building or improvement is sold within one year of completion,Ne owner.
builder will haw Ibe burden of proving Net he did not Wild or improve for purpose of
sok.).
1,as owner of the progeny,am exclusively contracting with licensed contractors to
consumer the pmjecl(Sec.7014.Business and Professions Code:)The Contracmr's Li
cense law Joes not apply to an owner of progeny who Wilds or improves thereon.and
who contracts for such projects with a cpmmcter(s)licensed pursuant to Jw Convenor's
License,Law. /
❑lam cxcmpt under gee .B&PCfar this mown Q l
cr Data /Q
WORKERS COMPENSATION DECLARATION
I hereby affirm under penalty of perjury one of the following deelaraenns:
I have and will maintain a Certificate of Consent to self-imum for workcr'sCampcn-
m1m,as provided for by Section 3700 of Ne Labor Case.far the perfonmene of the
work for which this peril is issued.
1 have and will maintain Worker's Compensation Insurance,as required by Section
3700 of Ne labor Code,for the pmformance of the work for which his Peril is issued.
My W rker's Compensation lnsunntt artier and Policy nu be"u"
4i� K[nl� Pa a.: 1759 SSS! 03
CBRTIFIC COMPENSATION
AN WORKERS'
COMPENSATIONINSURANCE
rola section need wt be completed Hire permit is for one hundmd dollars(51(X))
nr Icss.)
I unify that in the performance(if the work for which this Permit is issued,I shall not
employ any person in any manner so as to become subject to the Workeri Couradmiion
Laws of Cal ifomia.Dow _
Applicant
NOTICE TO APPLICANT:If,afar,making his Ciddiicam of Exemption, no should
become subject to be Workces Compensation previsions of the Toho Cab,you must
z Forthwith comply with such provisions or this Permit helf be deemed revoked.
?OCONSTRUCTION LENDING AGENCY
PM I botchy aline Nat dKrc is a tonstmetion lending agency for NC Performance of
aNe work(tar which this peril is issued(See.3097.CN.C.)
W Q Lender's Name
� z Lender's Add.
V O 1 cc dify that 1 have read this application and sale that the above information is
Ls, f-' correct.1 agree to comply with all city and county ordinances and spite laws feeling to
0Ubuilding construction,and hereby mention,rees presentativof Nis it ty to comer upon the
W ahow-mentioned property for inspection purposes, v
(We)agree to Save,indemai fy and kecis humlem do,City of Cupertino against
F"
C. liabilities.judgments.costs and expenses which may in any way acerae against said City
U z in consequence the gmntin s(this Permit.
�-^ APPLICANT D RST S AND WILL COMPLY WITH ALL NON-POINT Issued by: Date
SOU CEREG A
Re-roofs
ignaer f pp can✓Cadractor Da
7 J-411
HAZARDOUS MATERIALS DISCLOSURE Type of Roof
Will Ne apDlicam tar future building Occupant start or handle hvudous mammal
as defined by the Cupertino Municipal Cook.Chapter 9.12,and the Health and Safety
-1soy,2553xan ./meg-rater', All roofs shall be inspected prior to any roofing material being installed.
Will the applicant or of lure building Occupant use equipment or Jcvius which If a roof is installed without first obtaining an inspection,I agree to remove
it hazardous air contaminants as defined by the Bay Arca Air Quality Management all new materials for inspection.
it
❑Yes W.
I haw mad Nc hal nus materiais
o n reTmaer ntsnmwomrimu . requirements u'derehape,6.95
.95 o(tne Calific,
Seuore2 )5.25533sed25534.1udcrsd ifthe Wilding
1phraHcnaalN;NeSnyC ismymswnsihilnymnodlyticocupwtofNc
Set or wiasunce acc,dfieateaDepor .
Signature of Applicant Date
agent
DateAll roof coverings to be Class "B" or better