03100078-STRBKS CITY OF CUPERTINO �`^ ' ' K '� "- � - •--
BUILDING DIVISION PERMIT CONTRACTOR.INVO ATI N
0U1'DING ADDRESS: PERMITN0.03100078
000 �T_RVRNIS PR.9914 RE)
EWS NAME: PERMIT ISSUE DATE
f
NE: SANITARY N0. CONTROL NO.
ARCHITECT/ENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
G7 0
ion LICENSED CONTRACTOR'S DECLARATION Job Description
1 u❑ 1 hereby affirm Thal 1 am licensed under provisions of Chapter 9(commencing P
;zw with Section 70(g)nf DOixom3of NC Business and Professions Code,and my license is
:?y in full force and effect.
,qz License Class Lie.# DEMIZING WALL/EXTER:_ DOORS/ELECT PANEL
it-'c Data Contractor 2 SERVICE UPGRADE
3Q tJ` ARCHITECTS DECLARATION
d cei 1 understand my plans shall M..it as public rccarda
C Licensed Professional
OWNER-BUILDER DECLARATION
if 1 hereby affirm that I am exempt from the Contractor's License Law for the
.0 O following maxon.(Section](131.5,Business and Professions Codc:Any city or county
5$ which requires a permit to consbuet,alter,improve,demolish,or repair any structure
-=� prior h)its issuance,alsorcquires the applicant foramen permiuo fileasigned statement
;ze that he is licensed pursuant to the porvisinns of the Contractor's License Law(Chapter 9 Sq. Ft. Floor Area Valuato�000
It-$ (commencing wi th Section 700E of Division 3 of the Business and Professions Code)or
2 Nat he is exempt lampoon and the basis for the alleged exemption.Any violation of
Section 7031.5 by any applicant for a permit subjects the applican.to a civil penalty of g���' q�I�er00 Occu ane T e
not more than five hundred dollars(5500). P Y YP
0 I,as owner of the property,or my employees with wages ot their sale compensation,
will do the work,and the swmurc is not intended uroffemd for sale(See.7044,Business
and Professions Code:The Contractor.Licenm law does not apply to an owner of Required Inspections
property who builds
ro orimpmvcs thercomandwho am..,
work himselforthrougM1 his 704 - DEI N���®
own employees,provided that such Improvementswho am not intended or offered hr sdn.is Ir
however,the building or improvement is sold within one year of completion,the owner-
builder will have the burden of proving flat be did not Wild or improve for puryose of
sale,. APR p
[D1,as owner of the property,am exclusively contracting with licensed contractors to 0 2004
construct the project(See.7044,Business and Professions Code:)The Contootm's I.A.
cense Law docs not apply projects an owner of proper(who sends or improve thereon,and UUILDING
ho Law etsdo forsuch ly toawithe cor progeny
(s)licensed poor a poi c;Contractor's
�yi u Law.
M'd rm cxe u der Sec. ,B&P C for thism
•C er Data
KER'S COMPENSATION DECION
I hereby alfimt under penally of perjury one o(th following declamions:
1 have and will maintain a Cenifrcate of Consent m self-insure for Worker:Compen-
sation,ss provided for by Section 3]00 of the Labor Code,for the Performance of the
work for which this pent it is issoctl.
❑ 1 have and will maintain Can
Compensation Insurance,as required by Section
3]00 of the labor Code,for the performance of the work for which this permit is issued.
My Worker's Compensation Insurance carrier and Policy number am:
Cartier: Pel icy No.:
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE .
(This section wed not be completed if tW permit is for one hundred dollars p$100)
of less.)
1 certify that in the performance of the work for which this permit is issued.I shall net
employ any person in any mannerso ei to become subject to the Worked Compensation
Laws of California.Data
Applicant '
NOTICE TO APPLICANT:Jr.after making this Car ifiete of Exemption,you should
become subject in the Worker s Compensation provisions of the Labor Code,you most
�Q forthwith comply With Such previsions or this parmitshall W deemed revoked.
Zy CONSTRUCTION LENDING AGENCY
I hereby affirm Net there is a construction lending agency for the performance of
JJti the work for which this permit is issued(Sec.3091,Civ.C.)
JJ
Lender's Name
? z Lender's Address
Q 1 calory Bial I have read this application and state Nat the above information is -
y 6~- compact 1 agree to comply with all city and county ordinances and state laws relating to
Dbuilding conswctinn,and hereby euthome representatives of Nis city to enter upon the
NU above-mentioned property for inspection purposes.
CL (We)agree to save,odcmni fy and keep hamfless the City of Cupertino against
TA liabilities,ju me .coals ens expenses whirl may in any way creme against said City q
;J,Z in cmasequ n of c tomming of this permit [/_
^' APPLICA U ERSTAN NO WILL COMPLY WITH ALL NON-POINT Issued by: Dale
SOURCE T3DN
IDa Re-roofs
nature l'Applica mmoactor Date
HAZARDOUS MATERIALS DISCLOSURE Type of Roof
Will the applicant or future building Occupant stere or handle hazardous material
as defined by the Cupertino Municipal Code.Chapter 9.12.and the Health and Safety
code.Seaton 25532401 1, All roofs shall he ins acted prior to an roofing material being❑Yea YINm p P Y g ginstalled.
rWill the applicant or future building Occupant use equipment or devices which If a roof is installed without first obtaining an inspection,I agree to remove
d hazardous air contaminants as defined by the Bay Area Air Quality Management - all new materials for Inspection.
is0ict?
❑Yes XNu
I have reW one a. t simatarialspaquircmcnu under Chapter 6.95 of Bic Califon
nia HcalN&Safety ,Sec ns25505,25533md25534.lundc wdBiatirBic building
Jots not curnnJy v ate rat Nat it is my rcspowihility m noddy the Occupant of Bic
rcyuircmcnLL elpdortn' oanccofeCcruOca¢orOccu ay. Signa[ureofApplicant Date
ba9a Z� 3v
Owner or aetnori dagent Date All roof coverings to be Class"B"or better