00110119CITY of cuPERTN Vo
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CONTRACTgR INFORMATION:` -
BUILDING DIVISION P1JRI�IIT '
BUILDING ADDRESS:
ICOM MECHANICAL INC
L lb
OWNER'S NAME:
PERMITISSUEDATE
HE
SANITARY Nth. CONTROL NO.
ARCHITEC VENGINEER:
BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
LICENSED CONTRACTOR'S DECLARATION
Ib Description
OIp
I hereby errata Out 1 am limnsed under pmvisUms of Chapter 9 (commencing
with Section 7") of Division 3 of the Business and Professions Code, and my license is
in full force License Clasnd effect. Lic.S
COFFEE ROASTER
Dale Cmnwnor
ARCHITECTS DECLARATION
I understand my plans shall be used as public accords
Licensed Pro essianal
OWNER-BUILDER DECLARATION
1 hereby affirm that 1 am exempt from the Conuanor's License Law for the
following mason. (Section 7131.5. Business and Professions Code: Any city or county
which requires a Pewit to cnnStna:l, alter, improve, demolish, or repair any Structure
prior to its issuance, atm requires the applicant for such pewit m file a signed Statement
that he ialiecnud pu.uamtothe provisions ofthe Contractor's License Law(Chaper9
Sq. Ft. Floor Area
Valu tion
(commencing with Section 7000) of Division 3 of the Business and Professions Care) or
that he is exempt Oc.from and the basis far Ne alleged exempdon. Any violation or
3}1�, �ilpl�erpp
Occupancy Type
Section 7031.5 by any applicant for a Permit subjects the applicanuo a civil penalty of
not seam than five hooded della. ($50().
❑ 1. u owner of the property, or my employees with wages as their ale compensation,
Required Inspections
will do the work cad the swctum is not intended or offered for sale (Sec. 7044, Business
and Professions Code: The Contractor's License Law does at apply to an owner of
q p .
property who builds or improve, thereon, and who doessuch work himself or through his
own employees, pmvidcd that such improvements sac not intended or offered for We. IL
however. the building or improvement is mid within one ya r of completion, the owner.
builder will have the burden of proving Nal he did not Wild or improve for purpose of
sale.). -
O 1. as owner of She property, am exclusively contracting with licensed contractors to
convect the projen (Sec. 7044, Business and Professions Code:) The Conaumrb Li-
-
Cense Law does not apply at an owner of property who Wilds or improves Damon, and.
who convects for such projects with a cont.ctor(s) licensed punuant m the Contractot's
License Law.
-
O 1 am c.ampt under Sec . B & P C for this moon
Owner Dau
WORKER'S COMPENSATION DECLARATION
I hereby affirm under penalty of perjury ane of the following declarations:
I have and will maintain aCcnifam of Corium to self insum far Workcb Compcn.
lion, u provided for by Section 37M of the labor Code. Im the Performance of the
work for which this pewit is issued.
O 1 have and will maintain Wmktr's Campemadon Insurance, as required by Section
37W of the Letter Code, for the performance of the work for which this pewit is issued.
My Worker's Compnuatian Ensure= carrier and Policy mother art:
Cartier. Policy No.:
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
rfbus.tinu mcd nos he comNned ifthe pews is foram hundred dollars (SIM)
or lova)
I cenlfy Nat in the performance of the work for which this Permit a issued, 1 shall not
employ any person in my manner an IS to Wcame subject to the Workeri Cmnpenation
Laws of California. DStc
Applicant
NOTICE TO APPLICANT: IL after making this Cenifcam of Exemption, you should
become Subject in the Worker's Compcnsetion provisions of the Labor Code, you must
foMwith Comply with such provisions or this pewit shall he deemed Unclad,
CONSTRUCTION LENDING AGENCY
I hemby affirm that Vert is a Construction knding agency for the perfuwance or
thc Sash fur which this pewit i, issued (Sec. 3M. Civ. C.)
,
Lender', Name
Lender's Add.
I certify that 1 have mad this application and tum the the .bow WrOmadmn is
Correct I agme to comply with all city and County ordinances and slam laws Rlaling to
building camwnien. and hereby auNonze mpreuatnives of this city to enter upon Ne
"
show-mentioned pronerty, far impeCuan purposes
(We) ague 10 saw, indemnify and keep harmless 0te City of Cupertino against
Iiabilides, judgments, Casa and expenses which may in any way aceme against said City
in co esupsace of the granting of this Permit.
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT
Issued by: Date
SOURCE REGULATIONS.
Re-roofs
Type of Roof
sigaamm er Appfiean✓cenDa
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant orform Wilding occupant isore or handle hanrdo. material
.
u defined by the Cupertino Municipal Code. Chapter 9. 12, and the Health and Safely
Cele, SeCfion 25572(4)7
All roofs shall be inspected prior to any roofing material being installed.
❑Yes ONo
If a roof is installed without first obtaining an inspection, I agree to remove
Will the midicantar future building ..pan' adeequipment or devices which
,it ballrooms aircontanimnu u defined by the Bay Ana Air Quality Management
all new materials for inspection.
alflCl7
OY. E) No
1 have real she bwordems materials raPneancnu tarok, eloper G95 DOW Califor-
a.Health &Safely code, Sections MMS. 25533 seal ZDM, l undesstaud Na if tie Wilding
dote not c seemly time a moot, tom it u my mspons miry to wtif, the ace.p., of the
mgmi..enawhich most Is, met prior OrismaneeoraCertificate ofOccupancy .
Signature of Applicant Date
All roof coverings to be Class "B" or better
Owner
or authorized agent Date