00070048 (2) CITY OF CUPERTINO
BUILDING DIVISION PERMIT CONTRACTOR INFORMATION:
BUILDING ADDRESS: PIdIl r NO.
OWNER'SNr IBI.76 STUDY AVE
PHONE: BLACY FHUn' c 'O.
C s Z ARCHI'T[C(ENGINEER: (408) 934-8844 BUILDING PERMIT INFO
O tJ III.UG ELECT PLUMB MECH
er lj t, 1�=1 fel L=1 1=1'
<a
jLno thenED CON'IRACI'1lR'S DECLARATION 10b Description
O Z I hereby allirn (hat 1 am licensed under pmvisiaro err CM1apmr 9lvonnnencing
wSttWI
tiun] B
ish of Division Sof the Business un�,tpssiynr j:nO any
a is in full force and eReet.
Y C a V I,I.. CI Lic,a_
ma Dale c _ tR�IT� AC UNIT
A CIIITECT'S DECDECI,ARAf(N
H g I werxmnd nay pbms mall be used m.public records
S v o ucen.w Twat siantal
OWNER-BUILDIiR UECLARAfION
usi 1 hereby urBrna that I um exempt inim Inc Contractor's License Law liar the /
C Z< following reason.(Section 70.11.5.Bu.iba%.and IMdessions Coll Any city or county
F cwhich requires a permit to comuua,alter,improve,de rmloh.or regain any structure O
a, ptorlu its issuance.also rcquial applicant finsocn permit mfileasignedsnrmmnt
a. 'hat heis licensed porm:mttothe provisions onncContractors LilLaw LCmpmr9 Sq. Ft. Floor Area —Valuation
(nnnmeral with Section 7gM)of Division 3 of the Ravines,vad Prnfeeeionx Code)
or that he is eaentpl hat and the h ois far the alleged cv,o lion.Any violation
of Section 7031.5 by uny npplicum far l pernru rnbjc,l,the arpliwnl lour civil pvndty
antetmomthan r„b1alreddauarn(s5um. APN Number Occupancyll'Ipe
01.asownerofthe pmpcny,or my employees x;th xugea as their sole compensation.
will do the work,and the wvmum is rat intended ur created for sale(Sec.70H4.
Business and Prof ssions Code:The Contractor,Liceme Law does not apply to an 3751 1 004. wired Inspections
owner of propcny Who builds or improves thereon,and who does such work himself ,
or through his awn coplayecs,pmvidal that such improvements am not intended or
offered for.ale.If,however.the building or improvement Is sold within one year or — ROUGH MECHANICAL
omplelion.the owncrbuilder will have Iho burden of proving thin ha did not build or v�0 v
no.for adc.). 304 — ROUGH ELECTRICAL
01.msownerofheproperty.amesns clmivvlycafacingwonErrwd
ccontro
racr.to 505 — FINAL 'ELECTRICAL
anslruct the project(See.70,14.Businand Prores.ions Cnde:)'he Contractors
Licenaa law does not apply to an owner al property who builds or improves liberation. 508 — FINAL MECHANICAL
and who contracts for such projects with v crucia s)licensed punuant to the
Contmewrs License Law.
01 am exempt under Sec. B&P C for This reason
Owner Date
WORKI?It'S COMPENSATION DECLARATION
I hereby infirm under penally of perjury one of the hallowing dcelumtions:
1 0 1 have and will maintain a CeniGcale of Consent m self-imine for Worker's
Compenvtion, is provided for by Section PW of the LaMar Cde, for the
perf.an.m a of the work for which this Permit is issued.
0 I have and will nminmin Worker's Compensation Insurance,as required by Section
9714 of the Lubar Cada,for the purlunnunce of the work for whleh this permit i.
wed.My Worker's Cmnpenmlion hrmmaa ry currier and Policy number m<:
Carrier: Pulley No: ”
CURT IFICATION OI'EKEMI'f1ON FROM WORK(?RS'
COMPENSATION INSURANCE
(This section need not be completed if the Permit is for one handled dollar
(5I(10)or les.)
I certify thin in the pertimnance of Ire work lot which this pemait is isued.1
Oath Plot employ any person in uny all
so as to a N
Ixeome subject it, Worm'
Conapcn Luf Calilonnd.[)all[)allApplicants o aws'
NOTICE TO APPLICANT.If.afcr making,ho Cvmfi.n of Eaemplion,you should
bceome subject to the Worker'.Compensation previsions of the Ludar Code.you most '
Q O mithwida comply with such para ons or this ..it shall be droned revoked. _
f ^ CONSTRUCTION LENDI NO AGENCY
a } I hereby affiml that there is a construction lending agency far the performance
W of the work rot Mr,h this permit is'ns and(Sec 3097,Co.C.)
L Q Lemur's Name
U Z Lender's AJdross
U Q 1 certify that I have mad this applicmion and mm(hat the above rgarrnmion is
Lks t.. enamel.I agree to comply with all city and county ordinances and slate laws rdming
Q U in building cumtmrtion.and hereby authorize repre,r,val vo of this city to enter upon
} I4 he shove-mentimand propcny for inspection parro es.
(•' p, Dive)agree to save.indemnify and keep harmless the City of Cupertino against
fq Iiahibla,,judgmerm,coos rad ev,mr,,hien may in any way accrue agaimt said
C.7 City 1.eon.equmtee of him grafin,of this Permit
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT Issued by: C Date
SOURCE REGULATIONS.
Signature of Date Re-roofs ,
IIALARDOUS MATERIALS DISCLOSURE
wdl the apilicamur lunar,building occupant sore or handle hwal mmmial Type of Roof
m def nal by the Cupertino Municipal Code,Chapter 9.12,and the Health and Safety
Cola Section 2551214)7
El Yrs Cl No All roofs shall be inspected prior to any roofing material being installed.
whtheappliam.I come Willing seaabant Live cgaipmmnor devices wblda If a roof is installed without first obtaining an inspection, I agree to remove
all haaurdous dr cunmmi aura 1u all by the flay Area Air Quahly Mare'anal
District' all new materials for inspection. Applicant understands and will comply with
O Yes 0N all non-point source regulations.
1 have read the h....bar,mumrials rcyuiremems under Chapter 495 of he
California Health&Safety Cole,Sal 25505.25533 and 25534.I understand that
Aiidin,,d�,,"noentiyM1m'cu nnl.th:n it is my rolnmsibilitymnalify the
ts which Ms al prior m isuana nfu Ceni ficate of
' Signature of Applicant Date
- Durbte All roof coverings to be Class "B" or better
OFFICE