05030198 (2) CITY OF CUPERTINO ---
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BUH.DING DIVISION PERMIT CONTRACTOR INFORMATION:".,
II U I LD I NO AD D MISS: GRANITE ROCK PERMIT N0.U 5030198
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OWNER'S NAME: PERMIT LSEUR DATE
aNE: SANITARY NO. CONTROL NO.
ARCHITECT/ENCINVER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
_Oo LICENSED CONTRACnderpDECLARATION Job Description
�up 1 ionherebyTD affirm that I am licensed under provisions of Chapter 9(commencing P
ZW with Scnion]IXM))nfDiviaion5afthe Business end Pmfessinns CMk,and mylicenuis
5E21 infuliiftheandhff"'- A" Li .« � TI--PARKING LOT RECONFIGURATION/
=F,e Dale Contractor LANDSCAPE
'q Wj ARCHITECTS DECLARATION
�y a-a I understand my plans shall W used As public records
OyA
3ouCi Licensed Pmfcssional
to 5 OWNER-BUILDER DECLARATION
<F1 hereby affirm Jim I am exempt from me Cootmctah License Law for the
i O o Billowing reason.(Section 7131.5,Business and Professions Code:Any only or county
$ which requires a pennir or construct,Aller,improve,demolish,or repair any slacture
Fib
prior(it its issuance.also requires the applicant for such permit to rile a signed statement
i o mat he islicensed pursttamathe provisions ofOnComputer's License Dow(Chapter 9 Sq. Ft. Floor Area Valuation
aroF (coo me uci All wi th Section 7")of Division 3 of NC B usince and Professions Cade)or
i
her he is eaemft th:mprom and the basis for the alleged exemption.Any violation of $141740
Section 7031.5 by any applicant for a Permit subjects the applicant to a civil penalty of APN Number Occupancy Type
not more Nan rive hundred dollars(SSW).
P Y YP
0 I,es owner of the unpretty,or my employees with wages at theif.wdh cara'A'atlnn,
will do the work,and the sthrom.is not intended orafferad far mle(Sec.7644,Business2-L
and Professions Code:The Conmacmrb License Law does not apply N an owner of - 0 Required Inspections
property who builds or improvm menton,and who does such work himself or through his
own em ployccs,provided that such improvements are not intended or offered for sale.If.
howevcgNebis 11 the,or improvement is to withi n he dost ole mplction.Neowner-
nodoer will have the burden of pmvi ng Nat he 1I1 not build or improve for pmpore of
solo.).
❑ I,is owner of the property,am exclusively contracting with licensed contractors to
construct the project(Sec.7044,Business and Professions Cade:)The Contnetan's Li.
cense law does not apply to an owner of progeny who Wilds of on proves Hereon,and
who contracts for such projects with a pantomimist licensed pursua at to the Contractors
License Law.
❑ I am exempt under See. ,B A,P C for Nis mason
Owner Date /
WORKERS COMPENSATION DECLARATION \
I hereby affirm under penally of perjury one of the billowing declarations:
❑ I have and will maintain a Cenifeme of Consent to ulbinmm far Worker's Compton. (�
satinn,m pmvidcd for by Section 57BD of me Labor Code,for the performance of the
work rev whack this maintain
issued.
❑ I have and will mein min Wmkcr's Compensation w rkfor cc,h i,perm by section V
77W of the Labor Cade.for On performance of the work for which mise permit is issued.
My Wmka's Comrenvotinn Insurance artier an Policy numlmf a¢:
CamerA.T(sOf/NPofey No.:InC� y766 y6
3
CERTTA7FREMPr10N
FROM WORKERS'
COMPENSATION INSURANCE
(This union need not Ire completed If the permit is foranc hundred dollars(SIM)
e Ion.)
I eerily Oat in the performance of the work for which this permit is issued.I shall nor
employ any Person in any mannersn As m become Subject o the Workera Compensation
Laws of Colifomia.Date
Applicant
NOTICE TO APPLICANT:If,after making this Cenifca c of Exemption,you should
become subject to the Worker Compensation provisions of the Labor CMe,you must
.J O forthwith comply with such previsions m this format shall W deemed revoked.
,z_t q CONSTRUCTION LENDING AGENCY
rrr I hereby affirm mat there is a construction lending agency lot he Performance of
Ca the work for which this permit is issued(Sec.LFJ],Civ.C.)
(!J Q Lenders Name
tl
D Lender's Address
V Q I ttnee Nat 1 have real this
ty and
county
and seta Nat me stew information is '
D. F mrcn.lagrtcommply elm all airy and ceuntyordinances and city tolaws
ntrup ingm
Q V
above
enmeotioned iogand hereby authon mreprcsematives of mise eitymenmr upon the �
HW ahavomentioned property for inspection poriawhich ms V`"'�:J UL/V
1 (We)agree o save,indemnify and keep harmless the City o(Cuperrinm against
Z Iiabilities,ju,.ofthe groffind mfdi,ha
which may in any way accrue egainslsaid City
U z APPLICAbPfcUNDERSTANDS ANDWILLCOMPLY WITH ALL NON-POINT Issued by: Date
—^
SOUIlS9+(IEGU;A5/ ;/
° Re-roofs
$$
name cApplicanycorryachor Dam
/
HAZARDOUS MATERIALS DISCLOSURE Type of Roof
the applicant or(Mort building e.Chapter
mare on handle Health and
aetlefmcJ by the Cupeninn Mu�l Code.Chaumr 9.13,and the Health and Safny
Code.Sccden 35532(a)F All roofs shall be inspected prior to an roofing material beim
C]ye, Na P P Y g g installed.
PWill the applicant or(drum building occupant use cyuipmem or devices which If a roof is installed without first obtaining an inspection,I agree to remove
ill haaafdous air contaminants as Jefned by the Bay Arca Air Quality Management all new materials for inspection.
Divrimy /
❑Nos QN11
1 have read On WmNtms materials myvimments under Chapter 6.95 of Ne Califon
his Hc,IubS Safety CW c,Scerrens 25515.35577 and 25534.1 undersund thin if Nc Wilding
Jres AyyCarrendy hoc A tenant,Nat it is my ramandhility m nobly the meupsnt.(On
M GC cn hlchmustWmhtpdor M issurtnce Ola Comfit of Occasm
��� —^, Occup. � Signature of Applicant Date
P�wAcr uriuthnrircJ agent
Data All roof coverings to be Class r'B'r or better
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