04070189 CITY OF CUPERTINO
BUILDING DIVISION PERMIT CONTRACTOR INFORMATION '"
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BU ILDING ADDRESS: CUPERTINO CONSTRUCTION INC 111IT1oD.04070189
OWNER'S NAME: PERMIT ISSUE DATE
E:DANN SANITARY 0. CONTROL NO.
ARCHf1ECr'ENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
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app LICENSED CONfRACfOR'S DECLARATION Job Description
C I hcmby.(Koro Nat 1 am licensed under p evisimu of CTUPmr 9(commencing P
<ty++ wish Smuon1=f,`f Division Sof Ne BuGrcs,aM Pmfessum Code.and myliceve is
'oF in full forceanacffms Q DEMO (E) HOUSE
jqz License Class-h--Li..N
Jp
Data O_2 )/L COnmacbr
sur ��d f ARCHITECT'S DECLkRION
I understand my plans shall he used as Public seeds
�yU
;off Licensed Pmfcssionel
^ 3 Oat I am commit
from
DECLARATION
y 1 hereby lesson.(Elm Nat I am eusin from Ne Casino Co License taw fou shy
io0 followhich"oraPermit
70211.5.Business mrPm,demolish.
ormny city orcounty
y$ which reyuir.a pcnnit m tootle(,slur,improve,dcmolixh,m repair my stnmum
print m its issuance,also mquam,she nPlicant for such permit a file a signed so ument
donMis licenced pursuant to the Puvisoo of the Convectors License Law(ChaPter9 Sq.Ft.Floor Area Valuation
CZ (commencing wish section TWB)of Division 3 of the B.i.and Professions CMC)ser
W. $ that he ts exempt thmf ran and she basis for dW alleged exception.Any violation of
Section 7031.5 by any applicant for a Permit subjects the applicant to a civil Penally of 3 2&l5T8ddlBibu0 0 Occupancy Type
Out more Nan five hundred dollars(S500).
wil❑L os ownv of nu pmpmy m my emPuycn with wage u N.ir ml.tom.Bumpan,
and Pr lesions and Nc swaum muni inLMesmaw si areas rs apply US In"dross Required Inspections
and any wh Professions Code:The Conveeton. std who Law dors rot apply lf rd owner of q P
Own employ .providds or ed dov.chimprandwho aressuch work himanlforNnughhis
employ=.the
provided Nasuch improvements are not mended moRered(resale If.
holder(.Ne building.den of rot is hat did oro yew of Completion,N.owncry
builder will have rW WNm of proving Wt W did not Wild or improv for purpose of
salt.).
O I,as owner of the Propene•am dxdusivdy contracting with licensed contractors to
Construct Ne project(Sec.7044,Business and Pnfessmu Code:)TW Cotncu's LF
se.taw does nos apply u rov.m owner of property who Wild, impdisman.aM, r/
who contracts for such projects with a conuactor(s)licensed pursuant to the Contractors \)
License Law.
❑I am exempt under Sec B&P C for this mason
Owner Data
WORKER'S COMPENSATION DECLARATION
I hereby sffum under penalty of perjury one of Ne following declamtioo:
have and will mainuin a Crrifsa a of Consent in salt-Tune for Workers Compere
satin,as provided for by Section 3700 of Ne tabor Cade,for the perfmmance of Ne
work for which this Permit is issued.
C!�I have and will crainuin Workers Compensation Insurance as required by Section
3700 of the Labor Code,for Nc pcdonnance of Ne vers for which this permit is issued.
My Workers COLLmpensa,as le eraser carrier and Policy number are'
Carrier: ST a;; 7 k(VIJ Poll"No.: -�5 —_2 .
CERTIFICATE OF E)CEMPT]ON FROM WORKERS'
COMPENSATION INSURANCE
(This section reed not W completed ifft Permit is(moot hundred dollars($Alt)
or less.)
I unify Not in the Performance of the work for which this Permit is issued,l shall not
employ any person in any manner so as u buturn subject m NC Wortmi Compur adon
Laws of California.Date
Applicant
NOTICE TO APPLICANT:IL after making this Ccnifieau of Exemption,you should
become subject In the Worker's Comptain ion Provisio.of Use labor Ccvm,you must
Z foMwiot Comply with such provisions or this permit shall W deemed revoked.
Z O CONMUC'NON LENDING AGENCY
F. I hcmby affirm that Nem is a Conewction lending agency for the Performance of
W> dm work for which this permit u issued(Sec.3097.Civ.C.)
W Q Lender's Namc
Os lender's Address
Z Ste.
U I certify Net 1 have reed this application and sou Net the above information Ts
F' Centel.I agree to comply with all city and county enhances and sum laws misting to
0 building cortsvuetion.and hereby nbodm mpO.emnbes of this city u Cour upon the
{37 ahovc-mentionea Property for inspection pulp..,
F n. (we)agree to rev.•indemnify and keep harmless dm City of Cupertino against
rA Ilabllitlessjudgments,casts and expe.es which may in any way accrue.,.last se to City
U Z in consequcmc of the granting of on,Permit. Date
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT Issued by:
yv6zle�>
SOURCE REGULATIONS.
Re-roofs
Signature of ApplicanUCommetor
HAZARDOUS MATERIALS DISCLOSURE Date Type of Roof
Will do applicant Or future Wilding occupant store or handle hvardo.maurud
as defined by the Cupertino Municipal Code.Chapter 9 1,and the Holth and Safety
Code,Section 255320)? All roofs shall be inspected prior to any roofing material being installed.
rYes tg Nu
If a roof is installed without first obtaining an inspection,I agree to remove
Will Nc applicant or future building Occupant use equipment in devices which
I havardou.Sir convention.as dMined by the Bay Ana Air Quality Management all new materials for inspection.
nuriul
❑Yes C4Nu
I have road the Wrardaes materials requimmems under Chapter 6.95ofdo,Califor-
aieHcxllh&SxfctyCedo Sections 25505,25333 and 25534.1 understand that if one Wilding
dors not currently haw a Wont,Nat it is my responsibility u noufy dW mcupant of the
mqui¢mcnts which moa he meet PC req iaseana pf,Cctdfc teof Occvpaner. Signature of Applicant Date
;:;;Z ( ( 2 F-3^0 s� All roof coverings to be Class"B„or better
Owner or nlh.ond spot 15.m