00090157BUILDING DIVISION PERMIT I CONTRACTOR INFORMATION:
BUILDING ADDRESS:
mell"Rif.c ldlti
11)131 12H
*R_Anrn r
O O ARCIi1TECGENGINEER: '
RUE
Z Z y 5 LIhatEU CONTRACT'OR'S DECLARATION
° Z � � 1 hereh— y uBinn Ihm 1 am licensed der provisions of chapter 9 (commmncing
P9_ wish Sec,ion]fNlfgofUi'iunJofthe Husinessand Professions Code. and mylicense
a x g - I force a ffre
O U License la � Lic.tra
3 u. Date d�
Contra AT[ N
i- tS ° ARCHITECTS Ia, pth Aecord
I undorstand my pions shall he mad uv puM1lic records
py E r
m a.s� p O License) Pndeesinnul
°' W OWNER-BUILDERnn'the Contractor's
ul I hereby ,(Sian that 1 1. excmpt from the Contmcmro License Low for she
followF <
which
remon. (Section ]cont& Business and improve,
demolish.
Code: Any city or county
to F C which requisu o permit re construct, alcor, nt for such
demolish, orerepairasig ed swment
L 3 c� the] c slicarwdperso requires hovisio so for Comments; Limit
Low(stamment
,ha, he is licensed pursuant m the provisions Division
of the he Busters License law (Chapter )
(commencing s a with Section on a of Division J"I,he R,cd c. and Professions tis Code)
or that he is excmpt (any ll, m and thea teunfar the alleged exemption. Any violation
or Section than
s by any dr d dril for n Isctmit xuhjvco Oe applicant m u civil punchy
of nnl more then 0vc hundred dollnrs ($SINI).
❑ I, us owner of the property, or my employees with wages av their sole aunpcoammi ,
rill do She work, and ,he structure is not intended or offered for sale (Sec. 7D1L
Business and Professions CMe: The Convector's License Law rites not apply to an
r of property Who builds or improves thereon, and who does such work himself
or through his own employees, provided that such improvements arc not intended or
offered for sale. If, however, She building or improvement is sold within one year of
con,clu ou, She owncrhuilde, will have the burden of proving that he hit not build or
in for pamnsc "Isa le.).
❑ 1. mrof the property am exclusively contracting with licensed contractors to
conswn the project (Sec. 704.4. Entities, and Professions Coi The Cnntmcum's
License Law does not apply to an owner of property who builds or improvem thereon,
and who contracts for such projects with a contractors) licensed personal to Ne
Contractors License Law.
❑ 1 am exempt under Sec. . B & P C for this reason
Owner Dane
WORKER'S COMPENSA'T'ION DECLARATION
I hereby au inn under penalty of perjury one of the following declarations:
] 1 have and will maintain a Certificate of Comoro as self -insure for Worker's
Compensation, as provided far by Section 3700 of the Labor Code, for the
performance of the wod for which Nis pe rmi, lassoed
❑ 1 have and will mountain Worker's Compensation Insurance, as required by Section
3700 of She Labor Code. for She performance of the work for which Ihls permit is
wed. My Warker't Compmourem buurunce emirr and Policy nw ther ore:
Carrier: Policy No.:
CERTIFICATION OF EXENIIII'[ON FROM WORKERS'
COMPENSATION INSURANCE
(This seeded need wt sa eme,demill if Ne pem,it is far one hundred dl
IS 100)or less '
1 cent fy that a c performance of She work for which this permit is issued. 1
SNdI pt employ yr�'yGnnn m any cl,,arler so as to become subject m he Workers'
NUI ICE ill AYPLICAN I: It, atter crucing this Cctl Land, of Exclllption, no should
become subject to the Workers Compensation provisions of the labor Code. you must
forthwith comply with such prowmans ar this fermi, shall be domed revoked.
z
H CONSTRUCTION LENDING AGENCY
ai 1 hereby allim, fl u„here is a construction (Sec,
lending agency for pvr(onnunce
of the work for which ,hit fermi, is issued (See. 3097, Ci¢ C.)
Lender's Nana
Z Lender's AJdresv
V 0 ( certify that l have read this application and state thin he above information is
correct. I agree to comply with all city and county ordinances and state laws relating
C.7 to building construction. and hereby authorize representatives of Nis city to enter upon
,he above-mentioned fropere, forinsfectem purposes.
F. L (We)agree as>ave. indemnify and keep harmless the Cay of Cupertino against
rA liabilities, judgments costs and expenses which may in any way accrue against said
Q.i City in consequence mf the granting of this permit.
APPLICANT iRSTANDSAN WILL COMPLY WITH ALL NON, POINT
5
Signature o(APPlic
HAZARDOUlfc�
HAARDOU �y
S building
occupant
DISCLOSURE
Will y t applicant of future building vee. Chapter
stile 2, Handle Health
Safes l
as deRSed by the Cupertino Municipal Cade, Chopmr 9.13, and the t1e.J,h and Safety
Carle, Section 255120)+
❑Yes 0 N
Will Iheaa,hel nI nr tanum huildmg occ.gnn, use vquipmem ver devices which
'inazallous or conmminea, as defined by Om Bey Area Air Quality Mi ii,cmem
Dist e'!
❑Yes ON.
1 have send the hazardous mater id, na flu mems under Chapter 6.95 of the
California Health & Safety Crile, Sections 155115. 35533 and 25534. 1 understand Sha,
if the building Anes not currently have a ¢matt, that i, is my resprannili,y to edify Be
rcufant of,hc,c'aimmems whtijlc, most he mea prior 1. issuance or a Cenilisme of
Sq. Ft.
Issued by:
Re -roofs
Type of Roof
'PUCAI ION SUB MTh
00090157
sNITARY NO. CONTROL NO.
09/25/2000
BUILDING PERMIT INFO
BLDG, ELECT PLUMB MECH
Job Description
200 AMP PANEL CHANGE
Required Inspections
36618040.00
304 - ROUGH ELECTRICAL
507. — FINAL ELECTRICAL
505 — FINAL ELECTRICAL
Date
ENERGY
`ATI roofs shall be inspected prior to any roofing material being installed.
If a roof is installed without first obtaining,an inspection, I agree to remove
all new materials for inspection. Applicant understands and will comply with
all non -point source regulations.
Signature of Applicant I Date
All roof coverings to be Class aB" or better