04100193 CITY OF CUPERTINO - u ;law r '%�Mo
BUILDING DIVISION PERMIT A+�>''1'1.1�t'I. TQROAa +aON '
BUILDINO ADDRESS: - PERMIT NO.
04100193
OW NEWS NAME: PERMIT EWE DATE
GRANT r,, R.T.TZARRTW ('OWPR
E: SANITARY OL NO.
ARCHI'113CT/ENGINEER: - BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
yop LICENSED CONTRACTOR'S DECLARATION• - - - Job Description
thePm.d
9plan.
ed under provisions of Chapmr 9(commcndrg
wiNS inmBR ! �/�i�� SKYLIT. REPLACEMENT
_ k� LIn Comam°r CONTRACTOR: NULIGHT SOLUTIONS
C1'3 DE 'TION -Itt� - -- - — - - - - —
�+ Licensed PmfeuioW
'OWNER-BUILDER DECLARATION
1 hereby.from that I amexempt from the Convenors Licansa law for the
"o o following moon.(Section 7031.5,Business and Professions Code:Any city,or county -
$ which requires a permit to construct.alter,Improve.demolish,or repair any structure ..... .. 1 -.
prlorm its Issuance.also requires dm applicator for such permit to file a signed statement
ftieisllmtvedpmmanun Ncpmvialomofde Conuuwra LkenwUw(Chaptor9 Sq.Ft.Floor Area Valuat�*og000
gg (commeucimg with Swims 700()of Division 3nfthe Bminasaand PmPsaionsCade)ar
5 $ that ha in esempt therefrom and the basis for tie alleged exemption.My violation of
Sectio 7033.5 by ary applicant for.apemn mbjeeu the APpncant to.civil penalty of - APN.Number Occupancy Type,
not mom than five hundred dollars($500). .
❑.L as owner orthe property.or my employeas wish"Sea ss thetr sole compensation; 34241011 . 00
will do Newms ands:noCumtsnot License
Law ones,
apply
70 as Boer Of Required Inspections
and Prywh.b.Code:no Conthermo,License L essuch ret apply if ser rough of q -
ownerywyees,provided
Nereprove who deenuch odedorkim W(ed interim.
Ms
awnemployeus,provided improvement
vememis mid within
Tendedmo@ud for We ir,
however,the building uimpmprovin Ismide did m yearofcompletion,Neowmr-
ask).r will have We burden of proving that he did nm Wild or improv for purpose of
sale.).
❑I,u roma r or the property,sus exclusively contracting with licensed contractors to
construct the Profen(Sec.704/.Business and Professions Code:)The Contractor.LI- - -.- -
eceselawdoesnotapplymanown,or property who Wilda Or Improves teeuon.and
wMmmmroruuhpmje=Mi aconuacwr(s)Iiunudpmuantw Ne Const sae.
License law. (IX
❑I rm cacmpt undo See. .B h P C fm Nis... r5-v
Owner Data vj`
WORKER'S COMPENSATION DECLARATION
1 hereby+(firm under Mushy of perjury arc of the following dalarWorte
I ham and will mountain a Caruthers of Content to self-Insure for Wader,Camper. ._
salon,an provided for by Section 3700 of the Labor Code.for the performance of the
work for which this permit is issued.
Y,haw and will maintain Workers Compensation Insurance,as required by Section
3700of me labor Code.for me performance of the work forwhich this permit is issued.
My Wollme,Compensation Insurance cars!m and Policy nu Ncr are:
./7Ul/CER LDQ�0-A -
�C R IFICATE OF E%EMPf10 cNyfT�Wf.1 WORKERS'
COMPENSATION INSI/RAbb
Obis section teed Our the completed if the Permit is for one hundred callus($100)
I cool that in the performance of the work for which this permit is Issued.I NW not
employ any person in any manner an as to became subject m the Worimm'Compensation
Laws of Califomia.Dau -
Applicant
NOTICE TO APPLICANT.If.after making this Certificate of Exemption.you ahuuld '^" '• `" "`
become subject he One Worker's Compensation provisions of Ne Labor Coda you must
Z forthwith comply wish such previsions or this permit mail he doemcd revoked.
ZO CONSTRUCTION LENDING AGENCY
(-t Ihereby affrm that Nlending them I. construction lendingency far the,Performance of
ar7
the work for which thin permit is issued(Sec.3097,Civ.C.) -
6i 0 lender's Name
.7 Z lander.Add.
U0 I cenib that I have tend this application and sure Nu the short informa0un is
Ip, torten,I aims to comply with all city ad county ardinames and state laws totaling to
0 building construction.and hereby audwrim representatives of this city to enter upon me
W above-mentioned property for impaction purposes
(We)agree to sam indemnify and keep harmless the City of Cupertino against
y liabilities.judgments,casts and expenses which may in my way accueaNnst said City
t„)7 in consegusncc of the grommi,of this permit.
Fl APPLICA ERSTA DS AND WILL COMPLY WITH ALL NON-POINT Issued by: Date
SO C L IO
o Re-roofs
nu fApplicanVCanuuwr Dam
HAZARDOUS MATERIALS DISCLOSURE Type of Roof
Will the applicant or future building=upset store or handle hsordous material
as defined by the Cupertino Municipal Code.Chapter 9.11,and the Health and Safety
Cada,Section 25532(.)7 All roofs shall be inspected prior to any roofing material being installed.
❑Y, '
WIII the applicant or future Wilding Occupant tau equipment or devices which If a roof is installed without first obtaining an inspection,I agree to remove
it hazardous air contaminants as defined by the Bay Area Air Quality Management all new materials for inspection,
District? x1��It�
❑Yes ,' V No
I have read to havardres maudab uquimmuns underChapur 6.95 arrive Califor.
nu HcalN&S sty Code,Scnians 25503.25533 and 25534.1 undo dNuifon Wildin
doss t cu hero a unan4 Nu It u my rcaponsihllity w nodi mcupant of me -
wh must eLpn.rwisauuwcofs ref ignatureofApplicant Date
ro-71A All roof coverings to be Class"B"or better
Owncror authorindagent Dam