08110016 CITY OF CUPERTINO .� 3%
BUILDING DIVISIONPERMITCONTRAGTQRTNFOtMATI .N h
BUILDING ADDRESS: PERMIT NO.
20400 MARIANI AVE TBD — TO BE DE
OWNER'S NAME: PERMIT ISSUE DATE
ONE: v+ /`(IAaD TTI:RCtA
ONE: . CONTROL NO.
ARCHMICTIENGINEER: BUILDING PERMIT INFO
BLDG EIFCT PLl1MB MECH
o o LICENSED CONTRACTOR'S DECLARATION Job DESCrIpIlOn
U 1 hereby aRm Net 1 sec licenced under provisions of Chapter 9(commencing
n�s wiNSenim7Oks)of DiN on3of Ne Basi =dPmfcuom Cude.m .ylieemseu
offnfulltorma
Dn.z LiceCI RELOCT NEW GAS LINE ON ROOF TO (E) BOILER
nse C
Lm..
— cono-umr "BELLANTI PLUMBING INC.
AacxnEcrs DFcu T"1
� O IuedcrstanJ my pled xlWl be sued sspublip (VMgj �—
g O� Licensed predictions!S OWNER-BUILDER DECLARATION
x1 hcmb,aRrm that 1 am exempt from Nc Cmumano's License Law fol the
too fallowing mason.(Section 1031.5,Business and Pmrevsian Cade:Any city as county
3 ff which mcm.a permit to mecomM.enter,improve.demalivh.or n:pvir any Nvctum
— y prior In its issuance.slss mgmres the applicant for such permit to file a signed statement
ZpA0 Nat heulicensed pursuant tothe provisions ofNla
cContractor'sLimsew(Chapter9 Sq.Ft.Floor Area Valuation
gy $ (commencing with Basion 7000)of Division)of the Business and laminations Code)or 25000
That W u eo arm Lindrem sed the him r.the alloged eumpdon.Any vlolatfon of
Secdon70315 by any applicator far a permit subjects the applicant m a Civil penalty or APN Number Occupancy Type
not mom than five hundred dollars(13M. 31622018 . 00
❑I.u owner of dte property,m my wploycas with wages u timksele wmpenssdon,
wmdo the weft and themucmm is matimuWed afoRered for talc(see 7W,Business Required Inspections
and Pmfestloru code:The Conaaal.Ya Lunse n e Law doant apply m an numn Or q P
property who build,.improves thermm sed who does such wart himsel f ser thnngh his
awn employees,provided rhatmeh improvements are not imeaked mo¢emd for We If.
however,Ne building or improvement Is sold within One Year Of compledon,the omm-
builder will have,the hoo en of proving WI W did not build or improve for purpose of
aab.}
❑L as owner of the propenY•am melunjwly,containing with licensed monomers m
comtauct the projen(Sec.7014.Business aha Praf,tions Cade:)The Castroism'Ll-
.Law does not apply to an owner of property,who builds or Improves thereon,and,
who contracts far such projeces with a mnuanar(s)Emend patient to the Conusnor's
L.isman Law.
❑I am exempt under sem ,B d PC fes this mswn
Owner Date
WORKER'S COMPENSATION DECLARATION
1 Manny afftam under penalty of perjury arc of the following declamam e
I ham and will malnsim aeerd ieste of Caruem to x](Assum faf WerkeYsCompen-
avid..,as provided ferby Section 3700.(the Iib.Code.for the performance or the
wart for which Cris permit is issued.
37 1 haw and ri11 maintain Waftrls Co ce ofth va Inuor which
h required by Section
3700 of ko Isom Code,f.the performance of the wok for which Nu permit u lssue6
MyW.r�kae-la Compe.auon Insurance carriv and Poliry,npumber am:
Carrier..Tpu LL�JC fTl,=f ?oliry NO,:3ip50 `3YO0
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(Otis meaken need mtbec.ndcual ifthe immitis f.ane hundred dollars;(S100)
or lass.)
1 arofy that in the perform-ac of the work for which this permit is issued.I dtall rot
employ any person in my manavr an as to become subject to the Workers'CompearaGan
Laws of California,Date
Applicant
NOTICE TO APPLICANT.If.after making this Certificate of Exemption.you Amid
Woman subject m the W.kefs Compensation provisions of the Lab.Cade you mus
wJO forthwith comply with inch provisions.Nu pennitshml W domed arwAmd.
y t;;
CONSTRUCTION LENDING AGENCY
[—t 1 hereby,will.data dere u a coawuesion leading agency for the perf.ms.e of
O: > the wade 09'x
far which thte permit is issued(Sec.3 ,Civ.C.)
6Wi Q Lsndet,Name
O,z Lender.Md.
U O I certify Not I have and Nis appliudon and more that the show information is
F cwnea 1 agree b comply with LI city aha county Omi.x.ca and mate laws mixing an
OU building construction,and hembyauthoria mprnmudws ofthim city to enterupnn Nc
I17 above-mentioned propory for inspection purposes
�'lL (We)agree I.saw.indemnify and keep hormlen Ne City of Cupertino,paint
res liabilide;Judgments,con and calmoss which may In any way acme 4dmt said City
V Z eme quina of the grooving of this
r A LICANT UNDERSTAND D CO PLY WITH ALL NON-POINT Issued by: Date o
so cE R ATPD(s. !<-s-O gj Re-roofs
S u o Appli `caduC.mmcmr Dam
lrl ARDOUS MATEIUALS DISCLOSURE Type of Roof
Will dte applicant.form Wilding occopmr sort or handle hassfdoes materia
as Med by dm Cupertino Municipal Code.Chapter 9.11.and the Health and Safety
Code, Y.8531(x)?
[:1 [ All roofs shall be inspected prior to any roofing material being installed.
[:1 Y. ®Na
Will the applicant or future building Occupant air equipment of devien which If a roof is installed without first obtaining an inspection,I agree to remove
emit ha.dous air contaminants as defined by the Bay Area Air Quality Management all new materials for inspection.
Diuric17
°Yrs er
have mad Ne havaNws materiaUmquimmenta under Chapter 6.95 of Ne Califon
INJa,Sarcty code.Sccdms 25505.25533 an 42553.I a.dcnund that if the Wading
rot cmr dy haw•lona 4 that It u m Pd ilydity w otify Ne oceupant of Ne
.I..=,tdch qcove cart m' .fxnili eofampamy'cn Signature of Applicant Date
All roof coverings to be Class'%¢"or better
Oov��d.ccm Dam