05050079 CITY OF CUPERTINO 1. Q" "*� " u''A.,� "'•
BUILDING DIVISION PERMIT < ON'CRAC�TURINFiT,2MA.TQNu,
�z.a� .:4*°22�,4,.' .
BUILDING ADDRESS: PERMIT NO.J T CONSTRUCTION 05050079
OWNER'S NAME: PERMIT ISSUE DATE
tE: SANITARY OL NO.
ARCHITECT/ENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
�oo LICENSED CONTRACTOR'S DECLARATION Job Description
I Inreby afnrm Nat 1 am W
licensed under provoes of Clupm,9(mmmemin{
with Section 7030)of Division 3 ofth.Buatness and Pro/Colons Cad.,end my licenseis
in full form and.((e0.
j53 Lima.Cla. Lt..a REVISION--CHG ELECT.' PANELS (2)
�Contractor
a� I underaUnd my platou m
De. ARCHITECTS DECLARATION NO NEW PERMIT ISSUED/ORIG. #04090293
an ll be heed public rords
3
Mxd
Licensed AofeWansl
^
OWNER-BUILDER
OWNEER DECLARATION ECLARATION
I Wmhy from that Iem exempt from d Commuters Law for the0 following ean. ]1313.Business and Professions Code:Any city as county
which requires•permit u soMer.Improve,demolish,mr repair any nmcmre
prior N its IYYBMPrequires Me far such permit Wfile
4 signed Nmmmt
that licensed Possums.he Provisions of N.Conxtin's ucuslaw(CWpmr9
Sq.F[. Floor Area ValuationY
59
(commencing t lanorDvof Businessand ProfessionsCode)w
'bat M I4 exempt Ncrafrom and Me but,for thalleged exemption.My violation
of '
Section 7031.5 by any applicant for a permit subjects Ne applicant to a civil penalty of APN Number Occupancy Type
not more than five hundred dollen($500).
01,aownaofthepiopeny,mmyemploycawithwgesalhei,mi.compenadhn, 3.626090 . 00
will do Me work.end thesbeetumIs not intended moffered furwe(Ses.70a,Business Required Inspections
and Professions Cade:The Contri cmes Liana n Law donot apply to an e Owner of 9 P
pmMnywho Wlldsorlmpmve Nmmn,andwhodmimhworkhimalforduoughhie
Man employees,provided that such impncemmu art nninanded reoffered threats.I(.
however,the building ser improvement h sold within sae year of mmpledon.Ne owner-
bulmm will have du burden of proving that he did not Wild or Improve for purpose of
sal..).
0 1.u Owner of the property.am ealumvely warming with licensed comments to
convect the project(Sec,7044,Business and Profession Code:)The Contractors Li.
came taw dors not apply to an owner of propenY who Wilda at improve thereon.and,
who contracts tussock project with a contactor(!)lianad pursuant in the Contractor's
License law.
0 l ameampitumm Sm. ,B&P C for this moan -
Owner Data
WORKER'S COMPENSATION DECLARATION
I hereby affirm under penalty of perjury one of the fallowing declmtiom: '
I hew and vent..Intel.a Cenificate,of Consent to WIN....for Wmkee.Campcm-
adm,a protocol for by Section 37M Of the Ia ver Code,fm the Performance Of the
work for which this pemlt is Issued.
0 1 have and will maintain Worker's Compensation Insurer=,a required by Section
3700 of the Labor Code,for the perfoman=of Ne work for which Nie peml,is laded.
My Workers Compensation Insurance cafficr and Policy number are:
Cartier. Policy No.:
CERTIFICATE OF EKEMPnON FROM WORKERS' -
COMPENSA71ON INSURANCE
('ITh section need Out he completed If the Permit is for one hundred dnllm Is 100)
or las.)
1 certify that In the performance of the work for which this panel,is issued,I shall not
employ any person in any manner An As m become abject to Ne Workers'Compensation
Law.of ChAtmals.Dam
Applicant
NOTICE TO APPLICANT:If.After making this Ccnincate of Exemption,you should
become subject to the Worker.Comp.nadan previsions of Me ISWr Code,you most
.,O raMwith O mPIY with each Provisions ser Ni.MMIL shall he dared revoked.
Z pro CONSTRUCTION LENDING AGENCY
[—i I hereby afiren that Merc I.,construction coding gency for the perfomancc nr
C> Me work for which this permit is bound(Sm.3097.Civ.C.)
W QLendds Name
CA. z Lenders Address
V 0 1 certify Nat I Mw most this application and sum that th.=bow information is
W ^! comet.I agme to comply with all city and county mMnanm s and state laws missing to
SV' building construction.and hereby mNence representatives,of Nit city to enter upon Me
W above-mentioned property for lmpection purposes.
(We)agree in saw,indcmmfy And Amp harmless Mit City Of CuPenino against
pal liabilities,jud{menu,cost and expense which may in my way acerae against said City
in
of the
ing of
V APPLLICANTeUN UNDERSTANDS AMs rmit.
ND WILL COMPLY WITH ALL NON-POINT Issued by: Date
SOURCE REGULATIONS.
Re-roofs
Signatureo(ApplicanlDem
HAZARDOUS
ARDOUS MAiERIApentnoDISCLOSURE Type of Roof
WIII y t applicant m fMuni Wilding Occupant uorc m handle Health
maarial
As donned by the Cupertino Municipal Cade.Chapter 9.12.and the Health and Safety
Cad.,Section 8532(a)? All roofs shall be inspected prior to any roofing material being installed.
Oyu ON.
Will the applicant or filum building Occupant use equipment or devices which If a roof is installed without first obtaining an inspection,I agree to remove
t hexasdous m,comiamin.nt As donned by the Bay Area Air QuaOMy Management all new materials for inspection.
District?
CYns ONO
I haw mad the haaNnusnumrialsrcquimmcm under Chapterli.95 of the Caliror.
nice Health&Safety Cod..Soctions 8505.35533 and 25534.1 undcntand thatlydie Wilding
dace rot cumntly haw a,mane Nat it h my veponsibility in notify the Occupant of dee
requlremenu which most the met prior to issuan=ofa Certificate or Occupancy. Signature of Applicant Date
Owner Or amhorixedgem Dau All roof coverings to be Class wB"or better