04060035 CITY OF CUPERTINO
BUILDING DIVISION PERMIT `..CONTRAC"TOWINFORMATIO,�.N
BUILDING ADDRESS: PERMIT NOO 4'0 6 0 0 3 5
10201 BUBB RD
OWNER'S NAME: PERMIT ISBUE DATE
BUBB PARTNERS 004
E: SANITARY NO. CONTROL NO.
ARCHITEC ,ENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
col, LICENSED CONTRACTOR'S DECLARATION =1 O O O
mF 1 hereby affirm that I am lianed under provisions of Chapter 9(commencing Job Description
i`a$ wits Section 7t)(k)).(DivisionSofthcBusinessandProfcssinnsCode,andmylicenseis fig(
mu mro arta errmt. 2 NEW ROOF A/C UNITS l�Uli�9�1��'®
j�i Liavc Clan tic.g
Data Contmcwr
ARCHITECTS DECLARATION
.
an< 1 unticrsunJ my plans shall W used as public records J U L 1!5--2004
JyU
0 ty Licensed Pmfcssiunel n
'' g Oe,I..exempt
from
DECLARATION
BUILDING x<I I hcmhy alBrtn Nat I am exempt from tse Conuacmr's License Law for the
0 o following reason.(Section 7031.5.Business and Professions Code:Any city or county
K m which rtquira it permit to c.,,.,,alter,improve.demolish,a repair any strucmv:
$15000
yai prior m its issuance.also requires ted applicant for such Permit to file a signed statement
<
that he is licensed purmanuoNeprovision ofthe Contractor's LimnreLaw(Chapter 9 Sq.FL Floor Area Valuation
,.a (commencing with Section IWO)o(Division 3 of NC Business and professions Code)or
a. Nat he is exempt thcrefram and du basis for the alleged exemption.Any violation of
Session 7031.5 by any application for a Permit subjects Ne applicant te,a civil penally of BIOGCD
not more Nan jive hundred dollars($500). Occupancy Type
❑1,as owner of the property,army employees with wages as their sale compcnsetinn,
will do Newark.and the suvctum is not inteadcd oraRemd forsale(Sm.7044,Business
and Profcssinns Code:The Contractors License Law doe not apply w an owner of Required Inspections
property who buildsmimprow thereon.ind wh.da ,oaahwork himself.,through his
own employees,provided thatsuch improvements..of intended oroRered formic.If.
however,the building or improvement is old within ane year of completion,the owner-
builder will have the Written of proving Nat he did not Wild.r improve for purpose of
sale.).
f71 1,as owner of the pmpeny,am exclusively contracting with licensed contractors to
suuct the project(Sec.7049,Business and Prafasions Code:)The Contractor's Li.
eve Law docs mat apply w an owner of property who Wilds or improves themon,and
who contoces for such projects with a contractor(s)licensed pursuant to ted Contractors
License law.
❑lam exempt U761 Sec. B&P C for Nis maen
Ow� /r LRKERw fl4lz'!. Date
O 'S COMPENSATION DECLARATIO
1 hereby a1Bno under penalty of perjury ore of Ne following declarations:
have and will maintain a CeniRcme of consent to self-insum for Worker's Compete
7c,
n,u provided for by Section]700 0(dse labor Code.for Nc perf.rmoa of the
for which this permit is issued.
have and will maintain WoNars Compcnouon Insurance,u required by Section
of the Labor Code,for Neperformance of the tush for which tsu permit is issaJ.
Waders Compensatin Tnaunna artier and Policy nmbercr. Polity No.: _
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
Musuction need not bocomplmed film permit Isforoac hundreddollars($100)
or less.)
I certify Nm in the performance of✓,work for which this remit is issued,)shall not
employ any person in any manner so az an become subject to Nc Worlmd Compensation
Laws of Califom e,Date
Applicant
NOTICE TO APPLICANT:IL after making this Ceni rea c of Exemption,you should
become subject in the wohers Compensation previsions or the Labor Code,you must
.J Z forthwith comply with such provisions of this Permit shall W deemed revoked.
z CONSTRUCTION LENDING AGENCY
'r+ T hereby trillion Nal thea is a constmctum lending agency lot for performance of
C > Le wars for Which this perms is issued(see Sum,civ.c.)
Lc
2.6 ndcr's Namc
G L<nder's Address
V Q 1 certify that 1 have mad this application atm sate that the above information is
U, F' correct.I agree in comply with all city and county on inanom and aide laws relating to
O U building contraction.and hereby authorim represenutiva of this city to enter upon the
G above-mentioned property for inspection purposes.
(War agree to save,indemnify and keep harmless the City of Cupertino against
o-Fr V] liabilities,judgments.costs and expenses which may in any way accrue against said City
V Z in consequence of dm granting of this permit.
^ 5AQQ/PPtttt,P7777LLIRIC¢AA�(N�TT UU/UNDDEER��ST/A/[(�/B/��A,N�D,WILL COMPLY WITH ALL NON-POINT Issued b D
Re-roofs
lSfgnatur�pfApplican✓Conoacmr Data
HAZARDOUS MATERIALS DISCLOSURE Type of Roof
Will the applicant or future building Occupant sora or handle hazardous maudal
as defined by the Cupenin t Municipal Code,aspect 9.12.and the HcaIN and Safety
ode.SEYcn25532(e)? u All roofs shall be inspected prior to any roofing material being installed.
Will the applicant or future building accupant esu equipment Or mvkm which If a roof is installed without first obtaining an inspection,I agree to remove
haramous air conaminana as defined by th.Bay Arca Air Quality Management all new materials for inspection.
7c;-1--uVr
o /
❑Yeses
1 have mad Ne hommous materials requiremcm under Chapter b 95 of the Califor
Health A,SafelyCmi,SCCLana 355)5,25533 and 35534.1 undersand that if Jr.Wilding
not cu at e a hrrm t it is my responsibility w mu(y the Occupant Of ts4
iremc is Last Wmt ' r 1.iameoce or a Ccmrcaw of euPaney.
� v Signature of Applicant Date
or arircd agent Date All roof coverings to be Class "B" or better