08110052�V4z
zW
n<o,
Sim
ee .�
JtoU
;thy
/l v1
kt000ptl
-2i
XF�
CRE
BUILDING DIVISION PERMIT
)ING ADDRESS:
OWNER'S NAME:
rrnmh r Mi.
PERMIT ISSUE DATE
CONTROL NO.
ARCHrrECTIENGINEER: I BDG BEI.ECTGPER rrINF MECH
— PLUMB
LICENSED CONTRACTOR'S DECLARATION
I hereby affirm that 1 am licensed under provisions of Chapter 9 (commencing
with Section 70001 of Division 3 of the Business and Professions Cade, and my license is
in full fame and effect.
License Class Lic. R
Date Contractor
ARCHITECTS DECLARATION
I understand my plans shall be used as public records
Licensed Professional
OWNER -BUILDER DECLARATION
I hereby alLrm that I am exempt from the Contractors License Law for the
following mason. (Section 7031.5, Business and Professions Code: Any city or county
which requires a permit to construct, alter, improve, demolish, or repair any strncture
prior to its issuance, also requires the applicant for such permit to Ole a signed statement
dual he is licensed pursuant to the provisions of the Cantractor's License taw (Chapter 9
(commencing with Section 7000) of Division 3 of the Business and Professions Code) or
that he is exempt therefrom and the basis for the alleged exemption. Any violation of
Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of
not more than five hundred dollars ($50(l)_
❑ 1, as owner of the property, or my employees with wages as their sole compensation,
will do the work and the structure is not intended or offered for sale (Sec. 7044, Business
and Professions Code: The Contractors License Law does not apply to an owner of
property who builds or improves thereon, and who does such work himself or through his
own employees, provided that such improvements are not intended or olfemd for sale. If,
however, the building or improvement is sold within one year of completion, the owner -
builder will have the burden of proving that he did not build or improve for purpose of
sale.).
C91, as owner of the property, am exclusivel con tin with licensed contractors to
conswathe prole usin a f ' Code:) The Contractors Li-
cense Law do at apply to an n f pro pe he ilds or improves thereon, and,
who Contra ctq or such projects r contrac s) ' d pursuant to the Contractors
License law.
❑ 1 am exempt under Sery'J B & P C for this reason
Owner Date
WORKER'S t4PENSATION DECLARATION
1 hereby affirm under penalty of perjury we of the following declarations:
❑ I have and will maintain a Certificate of Cannnt to self -insure for Workers Compen-
sation, as provided for by Section 3700 of the Labor Code, for the performance of the
work for which this permit is issued.
❑ I have and will maintain Workces Compensation Insurance, as mquimd by Section
3700 of the labor Code, for the performance of the work for which this permit is issued.
My Workers Compensation Insurance carrier and Policy number am:
Carrier Policy No.:
XEMP
CERTIFICATE UPEION FROM WORKERS'
COMPENSATION INSURANCE
(Phis section need not be completed if the permit is for one hundred dollars ($100)
or Icss)
1 certify that in the performance of the work for which this permit is issued, I shall not
employ any person in any manner so as to become subject to the Workers' Compensation
Laws of California. Date
Applicant
NOTICE TO APPLICANT, If, after making this Certificate of Exemption, you should
become subject to the Worker's Compensation provisions of the labor Cade, you must
forthwith comply with such provisions or this permit shall be deemed revoked.
CONSTRUCTION LENDING AGENCY
I hereby affirm that there is a conuuctnn lending agency for the performance of
the work for which this permit is issued (Sec. 3097, Civ. C.)
Lenders Name
Lenders Address
I certify that I have read this application and state that the above information is
correct. I agree to comply with all city and county ordinances and state laws relating to
Wilding construction, and hereby authorize representatives of this city to enter upon the
above-mentone pre cdion pu
(Wel agree to save, indent fy and harml the h f Cupertino against
Iiabiliiies,judgments. costs and penes ich ma a an accrue against said City
in consequence of the grendn f this rmit.
APPLICANT UNDERST DS AN W PLY WITH ALL NON -POINT
SOURCEREGULA
igna ofApplicant/Contractor Date
HAZARDOUS MATERIALS DISCLOSURE
WiB the applicant or future building occupant store or handle hazardous material
as defined by the Cupertino Municipal Code, Chapter 9.12, and the Health and Safety
Code, Section 25532(a)?
❑ Yes allo
Will the applicant or fulum building occupant use equipment or devices which
emit hazardous air contaminants as defined by the Bay Area Air Quality Management
District? t�
0 Yes
Ihavc mad the hay on m cels mq�a-nd5
Chapter 6.95 of the Califor•
niaFlcalth&SafetyCode, to 505,255rhdcrstandthuiflhcbuiWing
,does riot currently haw n that it' notify the occupant of the
requirements
Dale
Job Description
INSTALL UV FILTRATION ON EXISTNG FOUNTAIN FOR
PUBLIC WORKS.
Ft.
APN
36931033.01
Issued by:
Re -roofs
Type of Roof
Area
Required Inspections
Date
valuation
All roofs shall be inspected prior to any roofing material being installed.
If a roof is installed without first obtaining an inspection, I agree to remove
all new materials for inspection.
Signature of Applicant Date
All roof coverings to be Class 'A" or better