00050014OFFICE
CITY OF CUPERTINO
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CONTRACTOR INFORMATION: '
PERMITNO.
BUILDING DIVISION PERMIT
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BUILDING ADDRBSS:
SANITARY NO.
APPLICATION SUBb ITTAL DATE
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OWNljlt'S Mr::
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ARCHITECT/ENGINEER
BULGINPERMIT INFO
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LICENSED CONTRACTOR'S DECLARATION
I hereby Affirm that 1 Am licensed under provisions of Chapter 9 (wo rramcmg
Job Description
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with Section 9000) of ision 3 ufthe Business andel PProfe,sione Code, Anda my littnee is
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ARCHITECTS DECLARATION
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Iundersund DIY plans sWllh used upublic minds
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Beamed ProfeuicrW
Oe, I Am xUR.DER DECLARATION
1 hereby .(loam that I em cusin from Ne Comnemh License Law for the
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following tiao^ (Satire 9031.5, Business and Rafessions Cade: Ary city a wunry
Sq. Ft. Floor Area
Valuation
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which rryuims A Permit m canwct, Alan, improve, &.]ads or mpar any svucture
priormitsissuance. Also requiresOnce Applicant for ouchpemduo Elaa Law(suxmem
be is licensed pursuant ro the provisions of the Law (Chapter 9
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andon.Ayvi Cndc)m
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(commwcixemiNSection ID00)orbasiion sfrth alleged
Wt he is exempt therefrom and Ne buil far the alleged cump(ian. Any violation of
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Section 7031.5 by any applicant for a permit subjects the aPplicanuo a civil penalty of
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not more than rive hundred dollars (3500).
I] I.aanwnnofthepmpeny,nmyempmynawimwapsu. eirwiecnmParoe m,
Required Inspections
will do the work, and ba .,am is nen imcndaloroRered for sale (Sec. 1064. Buainau
And Profeuiom Code: The C.Amemar't License Taw does Am apply in an owner of
property who builds or improve, deed n, W who docs such work himself or through
his own employees, provided That such intprosemems are nm imerded Or offered for
sale IL however, the building or impmvemenl is sold within one Ym rfcOWIE(iw. the
enbuilder will have the burden of Proving that W did not Wild or improve rte pur-
Pox of Ale.).
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I. ea PMxr of doe Property. am exclusively mounting with licensed cOnhactps to
construct the project (See. ION, Business and Professoriat Cade:) The Convectors V.
cense law does not apply to An owner of property who Wilds at unproven thereon, and
who contracts for auch pmjmts with a commends) licensee punuent to the Conuatura
License law.
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❑ 1 Am rx<mp, under See. . B & P C fee this erason
Owner Date
WORKER'S COMPENSATION DECLARATION
1 hereby affirm under toothy of perjury We of the following decluati0m:
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I have arta win a of CovanurCodinsure rte Workiname
37 of the
Ation. rex provided for by Savors J)00 of the labor Code, fm Ilse ped.muroe of the
for bySection
work for which Nis peon is issued.
❑ I have and will maintain Winker. Compensation Insurance, es requited by Section
31110 of the labor Code, fm the Pesfmmater of the work for which Na p .it is inued.
My Workers Compensation Inmraoee cams and Policy number am:
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Cartier:Policy No.:
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(This nion.hednd be complem if Ne permit is fmmla hundred dollnn(SIM)
An 1<n.)
1 certify that in Ne parfia. oldie work for which his permit is lamed.I shat
not employ, any tenon in any manner to as to become tul to the Workers' Compen-
sation Laws of California. Dare
Applicant
NOTICE TO APPLICANT: If, after inking this Certificate of Exemption, you should
became subject to Ne Wm , Compensation provision, of the Labor Cade, yen must
forthwith comply with such provisions or Nis panni, shat W tamed rooked.
CONSTRUCTION LENDING AGENCY
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I1lneby alRm that there is a construction lending Agency fm the petfomuntt of
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the work fm which this permit is issued (Sec. 3091, Co. C.)
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Leaders Name
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1 unify than 1 have read this Application And state that the above informed. is
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Acorral.
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I agree (. comely with all city and county oNitumea mi laws relating an
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Wilding cmuvuction. and herebyautboriss reprcawletives of Nis city to erect upon the
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Above memirnrd property for inspection turpnces.
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'We) agree IDI nave, indrmndy and keep Mwless the City of Cupertino Against
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habllitlea. judgmamts.ensuAadapenx, whichmay in any way AO,ma Against said City
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in mnxwueae of the granting of this Pewit.
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APPLICANT UNDERSTANDS AND WILL COMPLY W'I'I'[AALL NON-POINM
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SOURCE NF.GUTATIONS.
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Signatureof ApPlicanUConbac co Due
HAZARDOUS MATERIALS DISCLOSURE
Re -roofs
Will lheapplicant or future Wilding occupant store m handle huANws nuxrial
LA defined nd by the Cupertino Municipal Cede, Chapter 9.12, athe HAW and SAfay
Section 25532(a)?
Type OI ROOT
Code,
Y. C] No
WiI11M apPlirmtorfumre Willing Occupant use<quipnemordevices which
All roofs shall be inspected prior to any roofing material being
installed. If is without first obtaining an inspection
irconuminsnu As defined by the Bay Arca Air QWiry Management
a roof Installed
Yes ❑No
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I a ree to remove all new materials for inspection. Applicant
un er$tands and will comply with all non point source regulations.
Iha nod the huard.,m.vialr amaimmal under chapter 6.95.E the Cali
forma Health & Safety Code. Sections 25505, 25533 and 25536. I monistical Nat if de
building does not currently have a tenor#, that it Is my resmie hil'ny to notify the occupant
of the requbcmenu which must be trot prim w ismaroe oft Certificate of Omipancy.
Signature of Applicant Date
Owner err autboriAed agcn, Date
All roof coverings to be Class "B" or better _
OFFICE