05040168 CITY OF CUPERTINO � '
BUILDING DIVISION PRRMIT „CUN'TIi:A..C 'QR`INP'1JT.iMATTQIV ,,
a fi a "arcs: ?or-xm
BUILDING ADDRESS: PERMIT NO.
TECHCON 05040168
OWNER'S NAME: PERMIT 155RDAT0
WB[CART-0 PAMArrTnNW 17420 M0NT_R___. SANITARY O OLNO.
ARCHITECT/ENGINEER: BUILDING PERMIT INFO
BLDO ELECT PLUMB MEOCH
�oo LICENSED CONTRACTOR'S DECLARATION Job Description
1 hereby affirm that 1 am limwd under provisions of Chapter 9(commeaing
wIN Section 7000)of Dividon 3 of the Buil.and Prafc sinm Caae�and my limen is
•a� iaralraae.naerr«.�•L7 Lk.g_ 2 2j GAS LINE REPLACEMENT
Licenm Clw Can' .JJ �/q//per /�
�Ze Usa ARCHITECTS ter, i DECui A I i �-u//��/y�� �f lJY{ (1 � s�
IunMnunJ my plans shall be uadupublic rtenrM {WrI L.I'�r�J (J fpt/��(fi rf�®
3 555(7 (/�/�I'
Licensed Pmfe.sinnal
OatNEno exempt
DECLARATION A�
m I I hereby reaso .(lens that f 1. exempt Rum the Cocoons Co License Law for the Ar county /b /Z y
0o which following nne.a ml,, 703 1.3,Business ants improve.
demolish.
Code:Any city someone
sY C ��fy
$ which its Iscaapemdl re cores the altee impmm,h pCnnitt fire&sig anyytatement U
1prior ast M 1 its Issuance,p rsu requires provisions
for such permh to rile Law
statement
1g-z< that he lc lleenwiJ pu.uenlmthe pmvialons of the Comm�or'a License law(Chepmr9 Sq.Ft. Floor Area1 VaIUBIlO
eft$ (commencing with Station 7000)of Division 3o the Business and Professions Cade)or
6'+3
that he is exempt therefrom and the hauls for the alleged exemption.Any violadon of
Section 7031.5 by any applicant far a permit subjects the applicant to a civil penahy of '
3YV ilY C621d i-wy2teT 0 0 1 ibancY Type
not more than five hundred doll..($500} "
❑1.As an,of the property,w my employees with v.1.As their sale mmpensalm,
will do rhe wah,mddue structure is not intended or offered fa lale(Ses.7044.Business Required Inspections
.it Professimu,Code:Th Commax's Liceme,Law it.ns rat apply M 1st owneer of (I P
property who bui Ida Or Im provu thermn,and who docs suc h work Mmself or Nmu jh his
own cmploy ox,provided Na such imprmemenuam not Intended.Offered far We.It.
however.the building or improvement is wild within one year o(completion.the awuen
builder will haw the burden of proving Na he did not build Or Improve for purpose of
❑1,as Owner of the property,am exclusively contracting with licensed romacto.to
consumer he project(Sec.7011.Business and Professions Code:)The Cormsctor's U.
mass law docs not apply to an owner of propeny who builds or Improve,thereon,and.
who contracts for such projects with aconuator(G licensed pursuant to the Contractor'.
License Law.
[][am exempt under Sec. .B&P C ror this mumn
Or
Dow
WORKERS COMPENSATION DECLARATION
Or
1 heathy aBirm under penalty of perjury arc of the following declw0ons:
I have and will mdmain.CeNfin.Of cownl toa161nsum for Wauce.Cmnpen-
ation,a pmvldedfa by Sermon 3700 of the VMf COM•(a the pedamance of the
wants for which this permit Is issued.
❑1 hue and will maintain Worker's Compensation Insurance,As required by Section
3700 of the labor Cade,fa Ne performance of the work for which this permit is Issued.
My Worke Cnmpewit Ins ce mire and P1ry num sae
Ce.ie{{,fes Policy No.: D
ic,d Oil, CERT PTI N ROM WORKERS '
((TThhiissmilon Med notW canplcad Russ permit Is formic hundred dollen(SIr10)
or lee..)
I certify that In the performance of the work fa which this permit Is issued.I shall not
employ enyper.on In try member ser as to bacama subject to the Workers'Compensation
Law.or California.Dam
Applicant
NOTICE To APPLICANT:If.after making this Certificate of Exemption.You shouts
baame subjeet to the WOdtefl Compewrion provhloa of the Iaba Cone,you mus
.J O forthwith Comply with such provisions at this permll.hall m deemed revoked.
y CONSTRUCTION LENDING AGENCY
[�w l hereby allifm that there 1.a Construction lending genry for the Performance of
tai> the work for which this permh is issued(Sts.3097,Civ.C.)
W�M Leader's Name
z Lender's Address
U O 1 minify dust 1 bun mad this pplication and mate that the above Information is
I'.F correct 1 grist to comply with All city and county ordinances and tete law relating to
O V building consWclion,and hereby suthodarepaantslmaofthis city toenter upon the
[Tt move-roam oned pmpcny for Inspection purposes.
tF^+a (We).gree to lave,indemnify and keep humku the City of Cupertino ag.imr
In Ilablli0es,judgments.cera and expenses which may In any my acme against lead City
U 7 in consequence of the Starting of this permlk
l� APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT Issued by:9 Date
SO=R LATIONS. _l—
pls� C Re-roofs
Signaumgr Applic mnt.elor Dote
HAZARDOUS MATERIALS DISCLOSURE Type of Roof _
Will the applicant or future building occupsm sme or handle immune,maten.l
As dented by the Cupenino Municipal Code,Chapter 9.11,and the Health and Safety
Colo,Seaton 35332(a)7 All roofs shall be inspected prior to any roofing material being installed.
❑Yes Nu
WIII the applicant or future building occupant use equlpm rt of devices which If a roof is installed without first obtaining an inspection,I agree to remove
craft hannicns air contaminants u MMed by the Bay Am.Air Quality Management all new materials for inspection.
Dlsrin7
❑tics &we
I ham real the N.Anu maenats requiamem under Chapter 6.95 of the Califor.
ala Hoorn&Saletycmc,Section 25505,25333 and 2533/.l undershoot d.t ifft building
Mu not curmnlly ham.team,Nat it I.my pommel hllily to sadly the nmemail or the
mgg).rRy.,wy¢=mnu lte metist Wi amus too ccninma argry���O� Signature of Applicant Date
��— ^ y All roof coverings to be Class "B" or better
Owner oramhorimdsilent Dam