05050056 CITY OF CUPERTINO d "" '�"
BUILDING DIVISION PERMIT ZCoNTRACTOR I49F AT74N
BUILDING ADDRESS: JUST CONSTRUCTION PERMIT NO. 5050056
OWNER'S NAME: PERMIT ISSUE DATE
NE: SANITARY OL N0.
JARCHITECTAENGINEER: BUILDINO PERMIT INFO BLDG' ELECT PLUMB MECH
s�oLICENSED CONTRACnSDECLARATION0 I berobY alfren mat I an d underProvisionChapter 9(commencingJob DESC
�� wlm Smllen7IX1U)of Dlvidon3of NC Bualnwaad Profculon+Cotle.and mylRenu i+
in full force and cRect
iJ2 LI...! loan Ca.# ... TI--MODIF: (E) EXIT RAMP /
? HITECI'S DECLARATION � 1005
!l151i 1 undersand my plans Nall be used as public meet&
=ata Licensed Professional BUIL
Oat Ism exempt
From
DECLARATION ®INy v
I hRro affirm Net I am excmpl cram the Con ons Co e:My C Law for Ibe `ye�.�
5 p O following maw..Permit
t ]1131.5.Business and Professions Code: of b i county
$� which mquims•permit a ennsaucL alar,improve,demnlixh,or poll any nructmm
_ZZ�^ prim to is Issuance,also muuires the applicant forsuch permit to nlc a signed saamcm
FFp<
that hlslicensed pu.uantto rho provisions ofthe Contractor's License Law(chapter 9 Sq.Ft.Floor Area Valu hon
d m (commencing with Section 7")of Division 3 ofthe Business and Professions Code)or ,
mat be n easmpl therefrom and the basis for the alleged exmnptim.My violation of
Section 7031.5 by meq applicant for a permit subjects the applicant to a civil penalty or ,.,�,pyi,�T,,,, ,
not mom man Ow hundred doll.($500). 3 3 J PTU I Corp 0 Occupancy Type
Q 1,n ownerof the property,mmy employcu with wages.mehmlc competwtion,
will&thewmk,andmemamumi3m,inede4mo@.drmwe(Sea7W.BiWcas+ Required Inspections
and Profevdom Cade:The Contravenes Lime law duan rot appy to an owner of q P
property who builds or i m prows therman,and who dues such work himself or through his
now employcu,pmvided that such Improvements are not intended moRered intrude.If.
however,the building or Improvement Is gold within one year of eempledon,the owner.
Wilder will haw the burden of proving that he did rot Wild or improw for purpose of
aide I
ie.I
❑1.as owner of rhe property,am exclusively contracting with licensed contracts to
conswet tins project(See.7044,Business and Profusions Cade:)The Contractor's Li-
cense Law dean not apply in an owner of property who builds at improves thereon,and
who contracts for such projects with a contractor(s)licensed pursuant to the Contrmdon's
License law.
❑l am exempt under Sm .B&P C for this ream. .. /
Owner Dow
WORKER'S COMPENSATION DECLARATION ]n
1 herby aRmm under penalty of perjury one ofthe following dechurso :
❑I how and will maintain•Cemiliiana of Concent tomRIR"re for Worker's Compeer
nation,as provided fm by Section 37M or the Labor Code,Tor the performance of me
work for which this permit is issued.
❑1 hew and will maintain Worker's Compen.don Insurance,u required by Section
3700 of me labor Code.for the performantt orthe work for which this Permit is issued.
My Worke"Compensation Insurance currier and Policy number am:
Carrier: �',7�. MrPolicy No.: ORCERS'CEERTRRFIOXION FROM
'
COMPENSATION INSURANCE
rrl&suction road not becomplmW If me permit is forum hundred dollars($100)
or less.)
1 certify that In the performance of the work for which this permit is issued.I mall not '
employ any person in any manner out ss to become subject to the WorkcW Compensadon
Laws of Califomis.Dem
Applicant
NOTICE TO APPLICANT:If,after making this Certificates of Exemption,you should
become mhjea m the Worker's Compensation provisions of mu LIM,Csde,you mum
wJ O forthwith comply with seen provisions or this permit shall be&cmcd Reeked. '
z CONSTRUCTION LENDING AGENCY
P1 be.by a ima thm mc.l a construction lending agency for the performance of
C> the work for which this permit is issuad(Sm.3197,Civ.C.I
OWi Q Lender's Name
a Z Lenders Add..
V Q I certify that 1 haw read this application and ma mat the above information l "+
U,
^. torr""I"I'm 0 comply wins all very and county oNina.ee and au¢aw+Rlting to fat
C rV^ Wilding construction.and hereby mlhorim Rpresemadws of ml city to cera upon me
N
W show-mentioned property for IMPean P"pema
(We)agree to taw,indemnify and keep hmmleu the City of Cupertino against
y Ilabilidesjudgmena,coms and expense which may in any way ax..,.last said City
V Z in consequence of the granting of min permit.
a� APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT Issued by: Date
SO
7E REGULATIONS.
UisIh H 4rCU2 e ' S - a-05 Re-roofs
Signature of Ap Ticar Comraetor Date
HAZARDOUS MATERIALS DISCLOSURE Type of Roof
Will the applicant or future Wilding occupant mom"handle hwardou material
an dented by me Cupertino Municipal Code.Chapter 9.11.and Ibe Health and Safety
Code,section 15531(.). All roofs shall be inspected prior to any roofing material being installed.
❑Yu �ZNa
Will the applicant Or solum wilding occupant use equipment or devices whim If a roof IS installed without first obtaining an inspection,I agree to remove
II nauardoan air contamimms as denmd by f Bay Arm Air Quality Management all new materials for inspection.
District?
[3 Yes ItNo
I have mad the Wood.,material.requirements under Chapter 6.95 of the Califor.
nu Health&SdOyCode.Smd"a 15505,25533 and ISSN.I understood dm lime building
does not c...it,haw a tent.mat it l my responsibility in notify the occupant of the
requimmcnuch thust be met Prior to issuance or a Cenlncato of occupancy. Signature Of Applicant Date
It$;] /�—�^ ��—� All roof coverings to be Class"B"or better
Owner or ulkinmed agent Dow