04020147 (2) CITY OF CUPERTINO' +��hr* ysx� }syty"/rrp�y�yat� `+;/Y�@'�T`'''^„''
BUILDING DIVISION PERMIT CONXRA1.`�TQJR�,tt�\.C,rYORMATION, ,
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BmAINGADDRESS: DWK CONSTRUCTION 11MrrNo04020147
-R'S NAME: PERMIT Mn DATE
04
E; SANrrARY O. CONTROL NO.
(408) 615-1 lans
ARCHITECTIENGINEER: BUILDING PERMITINFO
BLDG ELECT PLUMB MECH
�10o LICENSED CONTRACTOR'S DECLARATION O O O O
I hereby aroma that I am licensed ender provid.ns.r chapter 9(commencing Job Description
wWSection]000 of Divhion Sof Ne Business endP rfeuin SCode,endmylierno.ie
in full forte o tl e« J �O a DEMO �1N®
LDlec�nx Cl Crng
ARCHITELTSDECLA ION �D
�i I undertund my plana shall be used u pis mcnrds - MAR _ 32004
De U
sed Licensed Professional
OWNER-BUILDER DECLARATION
I 1 hemby am.that I em exempt from the Contractor's Li«nx Law for the BV ILDIN
O O following mown.(Section 7031.5.Business and Professor.Code:Any city or county ■
$ which inquires a Permit to enmwrt,alto,improve,demolish,or mpair any swnum V
pdwmiuWuaocc.a mquimstMapplicantforsuchMmitmnkasigocdmw=nt
4 < Nat he is ll«nsW Purwanam tW Provisionsrf the Conuxmri Li«nsc law(ChePter9 Sq.Ft.Floor Area Valu tion
C�O (commencing with Section 9000)of Division 3 oftW Business and Proruaions Covet)or
$
that he is exempt therefrom and the basis for doe alleged exemption.Any violation of
Section 7031.5 by any applicant for a permit subject,the applicsntto a civil penalty of g jC1 �@r0 0 Occupancy net mom Nan Eve hundred dollars(S5B0). P y `7Pe
0 I.as owner of the property,or my employees with wages u their sole compensation,
will do the work,and Ne sanctum is not intended oraRemd(Cantle(Sec.7W,Business
and Professions Code:The Contractor's License Law doss not apply to an owner or Required Inspections
pmpeny w hn builds.,i mproves thereon,and who docs such work himml f ar though his
own employcns,provided thotauch improvements are not Intended oroRemd(.,sale.IL
however,the building or improvement it veld within one year of completion,the owner.
builder will hero the burden of proving that he did not build or improve for purpose of
cath.).
0 1,as owner of the property am exclusively contracting with licensed contractor,to
construct the project(Sec.7044,Business and Professions Cade:)The Commerce,U.
«tee Taw dust not pply man owner of property who Wilds or improv thexrn,and
who contracts for such project,with a con *)licensed pursuant to the Contractor's
License Law.
❑I amemosptunderSce .B,4PCfCathlemuon
cr Dam
WORKER'S COMPENSATION DECLARATION
I hereby shot under penalty of perjury one of de following declarations:
0 1 haw and will maintain a Certificate of Couenno self ionum for Wmkeee Compen.
sstion.as provided for by Section 3700 of the Latter Code,for in.pedmmat ..(the
work for which this permit is issued.
❑1 have and will maintain Worker's Compensation Insurance,u required by Section
3700 of Nc Labor Code,farNe to Carrie (.,which thiapc,mtris emorJ
My Worked Compete non Inwnnce cam and
Policy No.: _
•RTIFICATEOFE EMPDON WORKERS'
COMPENSATION INSURANCE
Misr section need not W completed If the permit is(moot hundreddollan(SIM)
or less.)
1 unify that In the p ofmona of of to work for which this permit Is broad,10.11 our
employ tnypmwn in any manner w u to become subject to the Workers'Compensation
Laws of Catlf�ply�I am
Applicant
NC TO APPLICANT':If,after making this Certificate o Exemption,you should
boo subject m the Worker's Compensation Provisions of the tahor CMa you most
OZ to with comply with such provisions or this Permit shall be d«recd mwked.
„Zv OCONSTRUCTION LENDING AGENCY
(—o 14 IWreby M.that them I. mnstrectinn lending agency for the pe,formm«uf '
ai 7 the work for which this permit is issued(Sec.3097,Civ.C.)
0 Undoes Name ^
z Lender.Add.
O Q 1«oily that 1 have mad this city
application and atom Nn the above sus relating is
0 U burmtt 1 agree ct comply with all city antl county madws;cus and sum levee relatingto
he
QU abowngconswctiroand hominy euthonmmoses.ivrs of this city menter upon the
Lr( ehovm(Wtirncdlre 1.ertysave rot emnify an keep ls.
Ly, LL (We)agreeto cove,indemnifyand keep harmless the City of against
nstsid City r;y in coisequncejudgments.the granting of this permit. may in any way accrue agelnn said Clty /
V A APPLICANT
or the granting of Nis permit.
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT Issued by: Date
SOURCE REG LATIONS.
Si
tm�ppB��utc.ntmg `� ��yg Re-roofs
HAZARDOUS MATERIALS CLO E 7/ pe of Roof
will the applicant or future buHNng occupants 11.h ousmatedal
fined by the Cupertino Municipal Code.Chapter 9.12,and tM Reach and Safety
Section 255324)7 All roofs shall be inspected prior to any roofing material being installed.
❑Yin �Nu
Will 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
ha'radous air contaminants as defined by the Bay Arca Air Quality Management all new materials for inspection.
Dianct7
O Yes �No
Itsv mad the hmeMllua mamrialsmquimmenu under Chaper6.95 rrthe Califor.
ni.H«IN a Safety Cadc,Sccdons255D5.25533 ud25534.1 undcmmnd Nmirthc building
does not cure sly how a teras,Not it is my responsibility to nudity the o«uPant of the
mimmcnor It brouraWmetpnormissuenccortCcrti «mofOc«Paney. Signature of Applicant Date
owner. uthorizedagent d d6 All roof coverings to be Class"B"or better