04080140 CITY OF CUPSRTINO + -= �' r _
BUILDING DIVISION PERMIT e shi, ACTO INkORMA1.10
BuaDINGADDRESS: BAY VALLEY CONSTRUCTION IN
eaMITNO.
04080140
! S)rq qTRIZENS GREEN BLVD
WNER'S NAME: PERMIT ISSUE OATH
E: SAMTARY HOA
OL NO.
ARCHITECI'/ENGINEER: BUILDING PERMIT INFO
BLDGEIELT PLUMB MECH
o t� o t�
�00 LICENSED CONTRACTOR'S DECLARATION Job Description
1 hereby affirm that I am o
licensed under provisions of Chapter 9(commencing
+� with Section 70M).f Division 3 of the Business and Profesdons Code,and MY Human is
^ in full force and effect.
g seClass Liv. TI--INTERIOR
Dae
ARCHITECT'S DECLARATION
�i 1 understand my plans ahall W used an public records
5 u. Licensed Professional
y OWNER-BUILDER DECLA0.ATION
5t I hereby.(Sec nd 11. exempts Ad the Conlnctort License Law o for Ibe
o following rtamn.(Section 7101.5.Baines and Professions Cade:Any city or county
5:0 S which Mquiros•Permit to marW 1,eller,improve,demollsh,or repair any structure
��' prior wits issuance.also requires the applicant for such permit to file a signed sntement
a< that W is licensed Pumunl to dm Provisions of the Conlnctor'e License law(Chapter 9 Sq.Ft. Floor Area Valu [Ion
8 (comer ncingwiNke on7")o(Divuion3oflhc BusirA dPnfeuiom CM)car -
'� that he u exempt uerefrom and the bads for the alleged exemption.My violation of
Section 7031.5 by any appliant for.permit subjau IW applicant M.civil penalty of 3 2x81N'DtCtD�r 0 0 Occupancy Type
not mom tun five hundred dolWat(f500).
0 I,u mwnu of the property,ear my wployca with wgu u their salecmnpennton,
will do the work and theswcme lsnolintendeimortered fonale(Sm.7044.Business Required Inspections
Add Prorenions Code:The Commolors License law does not apply m ns an owner a( q P
now con when Wlprovidmprovlbereco,andwha a«ssuch w�k oroffe dfor ughhis ������®
ownemployc M Provided Wtsnehrmprowmenuartnot chintended araQerdhruh is
hmcm,,the building or improvement Is said within one year of completion.the manner-
, Wilda will haves the burden of proving that he did not Wild or ImPmw for purpose of
i uleJ.
I.a owner of Uro property am exclusively contacting with licensed contractors to $ 2005
ontrud the project(See.7014,Bminets and Professions Code:)The Comment's LI- GGGfffSSSTTT��T
tnu lawdrm, Illy manowner ofproperty,who WildsorimprovthAeon.and ,,®aQ�'
wed amntrecu for each mmkaa with acanvateNq liavued puawnl tetheCmtrxetars BUILDING I p ®I 9 d�
Lkcnae lave. !env( L
Ellamem pt undo Su. .BA PC fa this moon
2 '
RKPR'S COMPENSA IaR TIEN
l beaby eM under penslry of perjuryof the fol✓lowing dalan0orts:
Ww and will m tintsmaCerdricau of Comem to self-Insure for WorkersCompen-
nation,u provided for by Section 37M of the IJWr Code,for Ne Performance often
work for which this permit is id.
❑I have and will maintain Workers Compensation Insurance,ss m umcd by Section
3]00of the IaWr Code.far Ihn pcdarmanee Of the work fnewhich Nu permit is laved.
My We
ComlensNoa Inaumhce ardu eM Policy number are:
Carder. Policy No.: '
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(TTle section need Amt becampleted lithe permit Isroros,hundred dollars(SIM)
or las)
I«ni(y that in the perfotmsnco of the work for which this Permit is issued,l shell not
employ any permit in my mamsm Ad As to become subject to the Workers'Compensation
Laws ear California.Data
Applicant
NOTICE TO APPLICANT:IL after making this Certificate of Exemption,you should
become subject w to workmen CompeAuation provisions of the LAW Code,you a=
.JO forthwith comply with such provision a this permit"I W deemed revoked.
z
In CONSTRUCTION LENDING AGENCY
t-A Ihcmby affirm that ten 1.a convection lending agency for the perfurmanceof
env > theu work for which this permit Is issued(Sec.J097,Civ.C
LeJ
Q ndcr's Name
D z I<nders Addrw
U OF I ttNfY Nu I low rad this application and ma that the abeve Information,u
n.U comma 1 agres te comply with all city and county ordinances And ante lawnsws rem
latint
building construction,and hereby authodso representatives or this city ed enter upon Ute
W above-mmnlionmd property for Inspection pugmsea.
(We)agree te save,indemnify and hep harmless to City of Cupertino against
in liabllma judgmenra.eau and expenses which may in Any way accrue against said City
U z In corveganee of to grandng of this pmmit.
^" APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT Issued by: Date
SOUR ER GULATIONS.
Re-roofs i-7
Sig of AppllcanVCentncmr Data
HAZARD MATERI ISCLOSUR Type of Roof
Will the appiiant er Futuro Wilding oaupml sort orhandle hscadous material
As defined by the Cupenino Municipal Code.Chapter 9.13,and Ibe Health and Safety
section 25532(.)7 All roofs shall be inspected prior to any roofing material being installed.
❑ll t 1 pp Na If a roof is installed without first obtaining an inspection,I agree to remove
will the applicant m fuuture Wilding occupant urn equipment m devices which
l hnardna cit cmouminsna u defined by the Bay Area Air Quality Mmagement all new materials for inspection.
iorict7
CYu tfR No
I have mad the h.nN/...
materials requimmencs under Chapter 6.95 or ft Califor.
nia Heal&Safety Code,ScNons 25505.25533 and 25534.1 understand that lfine Wilding
does not currently how a tenant,that It u my responsibility In notify the acuPanl or the
ayes' nH wnimh mesa be met prier to issuance,or a cenillcate of occupancy. Signature Of Applicant Date
: ! All roof coverings to be Class"B"or better
/ Owner or authodxed egcm Dau