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CITY OF CUPERTINO
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BUILDING DIVISION PERMIT
�:CONTRACTORNFORMAT ON
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DING ADDRESS:
MCKENZIE BUILDERS
PERMrrMITNos4090050
R'S NAME:
iE
PERISSUE DATEE:
SANITARY C OLN0.
ARCHITECT/ENGINEER:
BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
0 0 0 0
LICENSED CONTRACTOR'S DECLARATION
Job Description
of Chapter 9 (commencing
I WmAMMby eat I am licensed under provisions m
N
whh Suei ]g1U)af DivisionJof NC Business and Professions Code, end myliccns, is
mmnr a.rmn /�/((�Z ref.
Liccn lure Lic. g
REVISION -FLOOR LAYOUT
Dam o ComemrdY( •-
ARCHnECTS DECEARA
SEW LINE CHANGE \
I undAAmdily plans shall be used as pn1lie men
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Licensed Pnafcuional
3 OWNER BUILDER ON
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Contractor's Law ter the
exempt from the Contns
1 hereby .(Sore that 1 m
Any
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Co : c
o 1. dons Code: Any tiny or county
following, motion. (Section 7031.5.Business and
motio
improve, demolish, Or repair any structure
which improve.
which require a peau mpd.
aLu re ft Applicant for suede Permit in ccosele A gncd aumment
prior m its Lenced the Minnow
Sq. Ft. Floor Area
Valuation $0
o
a HommencmnudpuraantwNcpmviviomofNcuonuxmr'ali¢vclsonsCod¢rY
p to
$ that W is exam iNsection Division J nfdt.Ruvnexe and Professions Anyavi CMc)tar
Nes h u exempt therefrom and da: buts for de Ncged exemption. Any violations of
ronand the
APN Number
Occupancy Type
Sectors 7031.5 by any applicant for a permit subjects the applicant a a civil penalty of
not me. Nan Eve hundred d.IWA (1500).
35717069.00
01,uowner o(Ne properly, ar my employ=with wegn uNelr sole compensetlan,
Re aired Inspections
q P
will do Ne work.and themecmre is not invaded oroffered include (sea]OW, Business
And Prolessfass Code: The Conuacbrs Licens, law does rot appy N an owner of
.,
propemy who Woman, improv thereon. and whodoessuch work himullw through his
Own employ=, provided that such improvements art not mounted wagered fwaele If.
however. Ne Wilding or improvement is old within ane year of completion. the owner.
builder will hats the Wrden of proving that W did not Wild or improve for purpose of
sale.).
0 1. as owner of dm property. am esclusively contracting with licensed conlracmm to
construct the project (See 7814. Business and Professions Code:) The Contractors Li.
cents, Law d= not apply or an owner of propery who Wilds or improv Nerean. and .
who contra for such projects with a conu¢mr(s) licensed pursuant to Ne Contractors
License law.
I am exempt under See. , B & P C for this mason
cr Dau
WORKER'S COMPENSATION DECLARATION
1 hereby aRnn under pmuly of perjury me of IM following declarations:
have and will maintain a Certificate of consent to self -insure for Wortrrs Compcm
n, As provided for by Stt110n 3700 of the LAW, Code. for on Peeformanco of dse
work for which this permit is issued.
1 have and will maintain Worker's Compensation Inamince, As rtq.i.d by Sccdnn
3700 of he Libor Code, for the performmee Of the work for which this permit is issued.
My Workers Compensation Insurance carrim and policy number arc:
Policy
CERTICACATEOF PX EMPTI OMW0RKERS'
COMPENSATION IN URANCE
Mo section need not W completed If tW permit is lworsc hundred dollars (S 100)
car less.)
I certify than in the performance of No work for which Nis permit is issued, I .Nell not
employ any person in my raw;-utoba eFubje�n olM Wartrri Compensation
Laws of California f �% f K! Fy
Applicant f�
NOTICE TO APPLI hy. If, afar making his Cer ificam or Exemption, you should
become subject to be Worker's Corms nsanion provisions of the IaWr Code, you mus,
Z forthwith comply with such provision or his Permit shall W deemed mvokcd.
OCONSTRUCTION LENDING AGENCY
I hereby ARjrrn that there is a consnrocunm lending agency for IW perfomtance of
Ne work for which Nb Permit is issued (Sec. 309]. Civ. C.)
QLenders Name
z Lcndcr's Address
1 ttnify that I haw read Nis application and sum that the &hove information is
correct. l agree to comply with all city and county ordinances and su4laws mlating to
Wilding construction, and hereby auNorim mpresemaliv of this city to enter upon Ne
aWve.mcmiunedpmpcny for inspection
to sa
CL (We) a&m w. indemnify and keep harmless Ne City of Cupertino against
m.
.judgments, costs end xperwhich may in my way attroc agalnstsald City
N liebiliticsess,s which
&a
Z in consequence of the granting of this Permit
.w APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON -POINT
Issued Date
7/1
SOMER }. O S.
I -I),to('
fby:
s
Re -roofs
Type of Roof
Si f f,Comuctrr Dau
HAZARDOUS MATERIALS DISCLOSYgI
dl IW applicant or future W ilding aeeupmtsmm w handl. hmaedous material
As de0ned by Nc Cupenlno Municipal Code. Chapter 9.12 and f Health and Safety
.sited 235321&)?
Ycs
All roofs shall be inspected prior to any roofing material being installed.
If a roof is installed without first obtaining an inspection, I agree to remove
will Ne epPliaant or future Wilding use equipment or device which
s air conuminanu u defined by the Bay Area Air Quality Management
all new materials for inspection.
ter,mom
ct?
�Ycs �jNa
1 have mal the h=fdon matermismquimmcou under Chapter6.95 of the Califor.
nia Hcahh & SafeyCom, Seeuau 25505.35533 and 25534.1 understand Natif dm Wilding
d= not currently have a tenant that in is my m5pmuihility to nosey on, occupant of do
mq ntswMa ma dor sonic af.cOmficau aupancy.
Signature of Applicant Date
All roof coverings to be Class "B" or better
Co w v u agcm am