05060071 CITY OF CUPERTINO i^
BUILDING DIVISION PERMIT CONTTRACTR INFORMATION ,
BUILDING ADDRESS: AMS ELECTRIC PERMITNO05060071
19000 HOM qTRAT) Rn
ER'KAS NAME: PERMIT ISSUE DATE
ISER PERMANENTE 5673 W LA
PHONE: SANITARY NO. CONTROL NO.
(925) 225-1267
ARCHITECT/ENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
ump0 LICENSED CONTRACTOR'S DECLARATION Job Description
<�C I hereby affirm Nat 1 am licensed under provisions of Comer 9(Commencing p
w with Section 7")of Division 3 oflW Business and Professions Code.and my license is
n_'ny infuBmrveandn REVISION--ELECT. DRAWINGS
�ytz Licenx cl}g uen `�-
��o Dam m - Cantmclor AM - - NO NEW PERMIT ISSUED/ORIG. $ 05010092
ARCHITECTS DECLARATIOf
I understand my Plans shall W used as public records
�yU
iso Licensed Professional
3 OWNER-BUILDER DECLARATION
<2 1 hereby affirm that 1 am exempt from Ne Cin meter's License Law for the
Do following mason.(Section 7(n 1.5,Business and Pmfcssioni Code:Any city of county
K m which mquires a pemit
rIo Co.,.alder.improv,dem ili h,or.Pair any arumum
YZi prior m its issuance.also regvims the applicant for such Permit to file a signed statement
ESQ thatWu
islicensedpursuannNeprovisionsoftheContractor'sLicenselaw(Chapter9 Sq.Ft. Floor Area Valuation $0
'i- (commencing wild Section 7")of Division 3 of the Businev and Professions Code)or
y -
that he is exempt therefrom and the basis fa the alleged exemption.My violation of
Section 7031.5 by any applicant for a permit subjects the applicant in a civil penalty of APN Number Occupancy
not momthane five hundreddollars(M). 31609037 . 00 P y Type
❑I.asowncroftlmpmpeny,ormyemploycuwiNw .geauNe'usoleeompewtion.
will do the wart,and the structure is not hundred merited forage(Sec.7004,Business
and Professions Codc:The Contractor's License Lew does not apply in an owner of Required Inspections
property who builds or improves thcrcon,and who does such work himself or through his
own employ.,provided that such improvements am notinmMeL or offered formic.If,
however,the building or improvement is sold within mm year of mmpledon,Ne awrrer- A
builder will haw the burden of proving that W did not Wild or improv for purpose of !\
sale.). -
❑1.as owner ej Ne pec.in,7(u ,B sine siv nd conuacting with:)TheeCoanuuton U. S
constructLades not (Sec.to in
Business and fry who
Cade:)TheContractor'sthe tar's W
Comm law docs not apply m an owner oiprops(who builds or improves Nerton,and
who cantmcu for such projects with a canvumr(s)licenxd pursuant to the Conwcwrs
License Law.
❑Ism exempt under Sec. ,B&PC for this rtuon
19 1 Dam
WORKERS COMPENSATION DECLARATION
1 hereby affirm under penalty of perjury one of the following declarations:
❑1 have and will maintain a CeNfmate of Cmucnuoself-insure for WorkeesCompcn-
sation,as provided for by Section 3700 of the Labor Code,for Ne performance of the
work for which Nis permit is issued.
❑ 1 have and will maintain WorFch Compensation Insurance,as myvired by Section
3700 of the labor Code,for the performance of the work for which this permit is issued
My Workers Compensation Insreance carrier and Policy number an:
Carrier �VYI YCV Policy No, W"1W 1'L
CERTIFlCAM OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(This section need not be completed if the permit is for one hundred dollars($11X)
or less.)
1 mniN Nat in tW performana of the work for which this permit is issued.I shall raw
employ any person in any manner x m to become subject to the Workers'Compensation
Laws of California.Dam
Applicant
NOTICE TO APPLICANT:If,after making this Certificate of Eaemption,you should
become Subject to the Worker's Compensation provisions of the Labor Code,you most
.J z forthwith comply wild such Provisions or this permit shall W deemed revoked.
ZO CONSTRUCnON LENDING AGENCY
F I hereby affirm that fere is a construction lending agency for the performance of
a� ft work in,which this permit is issued(See.3097.Civ.C.)
W Qlender's Name
=a.z lender's Addm..
U O I century that 1 have read this application and sum that Ne above information is
f•' coned I agree to comply wild all city and county ordinances and sum laws misting to
UU building construction,and hereby authorise rtpmentadves of this city to enter upon the
N L07 above moniioreA property for inspection purposes.
(~ gy (We)agree to save.indemnify and keep harmless the City of Cupertino against
N Iimilitiea,judgmeno,costs and expenses which may in any way accrue against said City
U z in conami ence of the granting of this permit.
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT Issued by: Date
SOURCE
LATNS
&DMS✓4 6-349L pS
Re-roofs
Signature of APPlic on - Dare /
HAZARDOUS MATERIALS DISCLOSURE Type of Roof
Will the applicant or future building occupant rota or handle haessilous mamrial
as defined by the Cupertino Municipal Code,Chapter 9.13,aM IM Health add Safety
.ScNon355320)7 , I All roofs shall be inspected prior to an roofing material beim
❑Yes / ON.,
P P Y g g installed.
Will the applicant or fuwao Wilding occupant tic equipment or devices which If a roof is installed without first obtaining an inspection,I agree to remove
amlt hazardous air com in idents as defincd by IW Bay Area Air Quality Management all new materials for inspection.
Disom,?
❑Yes No
1have dead fiede sections 25505. requirements under Chapati WALif fie C.Wilding
rm-
digs noth&Safcy Code.Sadomhat it is
niand25534.I undersand ldniDW Wilding
Jots not currently haw a tenant.that 0 is my rapoosihility,In notify IW occupant of the
myuimments,which mustbcmplpriorichmanceofa Cerdramaf0scupancy. Signature of Applicant Date
/t,,� 4. 11lDM (-?mos
Owner oraumoriaed gen D,m All roof coverings to be Class"B"or better