05060022 (2) CITY OF CUPERTINO . ۥ
BUILDING DIVISION PERMIT CLINTRAGTORINFORMATION ,
BUILDING ADDRESS: F PERMITN905060022
OWNER'S NAME: PERMIT ISSUE DATE
E: SANITARY NO. CONTROL 10.
ARCHITECDENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
u®rLICENSED CONTRACTOR'S DECLARATION
w❑ l hereby affirm that l am licensed under provisions of Chapin 9(commencing Job Description
<W with Section 70ay.(Division 3ofdoo Businessd Profession Cock.md my her.is
-]y in full fora and cff
>�� License Class —L Lm.. �� ( CJS^� SIGN--WALL SING W/ELECT.
=to oath Crude..,nCONTRACTOR: CENTRAL—SING SERV.-IDES
ARCHI'fECI'S DECLARATION t ``
I understand my plans shall W used as public neords 'J
JaU u �✓_�(i fI1J/J
vi Licensed Porfessinnal
ve
3 OWNER-BUILDER DECLARATION
1 hereby ul'firm that 1 am exempt form the Contractor's License Law for the U�5
00 following mason.(Secdon 703 IS.Business and Professions Cad2
Cade:Any city or county L
ff which requires a permit to convect,alter,improve,demolish.or repair any structure
Fla
prior it)its issuance,also requires the applicant for such permit to file a signed statement
Oat W is licensed pursuant to the provision of the Common's Ila•.-Law(Chapter 9 Sq. Ft. Floor Area {�II II * Valuatgo�
mac (commencing with Section 7001 of Division 3 of the Business and Professions Code)or D fI nnj{ ���`\�l{rp/�Y 000
w. Oat he is exempt therefrom and the basis for the alleged exemption.Any violation of U II jL � tl� 1\\i�
Section 7031.5 by any applicant for a permit subjects cite applicant a civil penally of APN Number -Occu ane Type
not mom man fiw<hundred dollars(5500). -occupancy YP
❑1,u owner of Ne pmpeny,or my employers wire wages ss Meir talc compensation, 35908018 . 00
will do the work and me structure is not intended or offend for sale(Sec.Mao,Budnw
and Professions Code:The Conlncmes License taw dos not apply to an owner of Required Inspections
property who builds or improves thereon,and who does uch work himself or through his
Own employees,provided mat such improvements am notimended oro@real for sale.IL
however,the building or improvement is sold within One year of eompinion,the owner
builder will have the burden of proving that W did not build or improve for purpose of
sale.).
❑1,as owner of the property,am exclusively contracting with licensed contractors to
consoo t be project(Sec.]Wal.Business and Professions Cade:)The Contractor's Li.
cense law does not apply to an owner of pmpeny who Wilds or improves thereon.and
who concocts for such projects with a contractor(s)licensed pursuant o the Con0amah
License Law.
❑1 On eaerept under See. ,B At P C for Nis rcsson
Owner Date
WORKERS COMPENSATION DECLARATION
1 hereby eRrm under penalty of perjury one of he following declarations:
have and will maintain a Cerhfieate of Consent to self-insure for Worleefi Compere
1031.,l
n,as provided for by Section 3]00 of the labor Code,for the performance of be
for which this permit is issued. '
have and will maintain Workcts Compensation Insunna,u required by Section
of the labor Code,for me performance or me work far which this permit is issued.
Worker's Compensation Insurance carrier and Policy number am:er. Policy No.: _
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(This section need not he completed if me parmh is foram hundred dollars(SIM)
Or It..)
1 cenify that in the performance of the work for which his permit is issued,l shall not
employ any person in any manneran as to Weomc subject o the Worker'Compensation
Lawsof Cabfpprnia.Dam
Applicant a..5 w tvw LA G TxTYITt S l b
NOTICE TO APPLICANT:If,after making this Certificate of Exemption,you should
become anbjco w the Worker's Compcnation provisions of he LaWr Code,you muss
0 z foMwith comply with such provisions or this permit shall be deemed revoked,
Z O CONSTRUCTION LENDING AGENCY
F-'� I hereby affirm that user is a eonsuumion lending agency for the performance of
C4 7 me work for which this permit is issued(Sec.3097,Civ.C.)
d Lender's Name
D z Lender's Addrtss
U 0 1 cenify hat 1 have read his application and sate that thc a Wn information is
(L P^ comecs I agree to comply with all city and county ordinances and sues laws elating to
0U building construction,mdhereby auhomiirn representatives of this city to enter Open Ric
C ahom-mentioned property for inspection purposes.
(We)agree m save,indemnify and keep harmless he City of Cupertino against
F res liabilities,judgments,costa and expenses which may in any way accrue against said City
Uz in con Old, gmmingafthispermit.
^-� APPL NT ER N OMPLY WITH ALL NON-PoINT Issued by: Date
SOUR GUL N
—� Re-roofs '
Sign not Applican C tractor r Dau
H ARDOU$MATERIALS DISCLOSURE Type of Roof
Will the applicant Or future building Occupant store or hamile hvardous material
as defired by the Cupertino Municipal Code.Chapter 9.12.nd he Health and Safety
Cate.Section 25532(a)? All roofs shall be inspected prior to any roofing material being installed.
Ye
If a roof is installed without first obtaining an inspection,I agree to remove
Will me applicant or future building occupant use e.Air Qu or devices which g
hazardous air conuminanu u dcfncJ by tW Bay Arca Air Anality Martagcmcnt all new materials for inspection.
16rio? C
❑Yes /J�lsp
I have reel he Wrardousmamrials requirements under Chapter6.95 of he Califon
nu Health A, a ,Section 255(15.25533 zrx[M34.1 understood hatifhe Wilding
dos not to dy have re 4 Oat It is my rcammechility to madly he occupant of the
m wh em pdorwissuanaofaccitiricateoroccupancy. a� Signature of Applicant Date
6
Owner r amomfind ligen, Date All roof coverings to be Class"B"or better