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CITY OF CUPERTINO
BUILDING DIVISION* PERMIT
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BUILDING ADDRESS:
SON GENERAL CONSTRUCTION
PERMIT Nth 4110 0 7 6
2281Q MER
34 DOVER CT
SANITARY NO. CONTROL NO.
(650)222-4502
ARCHrrEGT/ENCINEER: ..
BUILDING PERMIT INFO
•
BLDG ELECT PLUMB MECH
(rj LICENSED CGNTR D CLARATIDN
by t neonaed elapler 9
Job Description
1 amrnr LIw ern on pro. ms ter eCommcncing
IN 70f10) of Dlvlalom ]of the B [cssitrna eadc,.nd my xecxhx is
. .
- -- . -' - - - —
inrul o ' snderc
REVI S ION- - IN HOUSE USE ONLY
z Ide m hash R
Due ComfaCWr�� . s�
NO NEW PERMIT , ISSUED/. ORIG. 404050029
ARCHR'EC-TS DECLARw770N
I understand my plans shall he usad as pudllc
y Lu d cBh 1
OW NER-BUILDER' DECLARATION
7 1 hereby affirm that I am exempt from the Conuartars License Law for the
o folktwinp ressoa (Section 7031 S, Business and Profasioei Code: Any city a county
9 improve,
which requires a permit w construct. alter, dcmulLth, err repair say suuctare
prim to its issuance. also requires the applicant rat such permit w file a sigmed Aatement
that belsllecnscdpursuant tothe provisions nf the Conuactor'sLkxnselaw (Mitter9
Sq.Ft-Floor Area
Valuati($1115 -
G
(commencing with Section 7000) of Division 3 of the Business and Professions Code) ur
_ that he is exempt therefrom and the basis for due alleged exempdon. Any violation of
Section 7031.5 by any applicant for a perm4 subjects the appliont to a civil penalty of
more than Loa hundred dollars
APN Number
Qccupancy Type
riot (S5W).
34222044.00
❑ I, as owocr or the progaty, or my employes wile wags at weir aesk txmpernatlon,
wide do the work and the structure b not Intended or Offered for sale (Sex. 704a, Business
and Professions Cc&: The Conbsctoes I imn- Law dam not apply to an owner of
Required Inspections
pmpLny who builds or improves thereon, and who does ouch work bionselfm duough his
own employees. provided that such Improvements are not Intended or offered for ask. If,
however, the building or improvement is sold within one year of cmnpletim the owner.
�p
builder will have the btuden of proving that be did not build or Improve for purpose of
sale
O 1.. u owner of the propesry, am exclvivefy comnrtxiog with Ilr:rued comvacters to
construct the (Sec. 70K Business Professions Code:) The Conuaemrs
<
project and U-
tense Law dots not apply to an owner of property who builds or Improves thereon, and
who contracts for such projects with a contractor(s) licensed pursuant to the Ceetraaorl
LicensLaw.
❑ 1 am exempt under Set. , B & P C for this reason
owner
Owner Date
- -' --. - - '
WORKERS COMPENSA7ION DECLARATION
I hereby affirm under pmiaiy of perjury one of List following declarations:
haw and will maintain a Certificate of Conwtt to"K-Insurc for Worker's Compen•
salon, Y provWed forby Secdon 3700 or site Labor Code. far.the petfarmanee of the
- -
work fW which this permit Is luood.
❑ 1 have and will maintain Workers Cmnpensation lnsun=, as required by Section
37M of the Labor Code -for the performance of the work for which this permit is issued
My arkers Comrpeasati0m IaLtunRCe carriu and Policy amber are:
_
. .
Carrier. Policy No_
CERTIFICATE OF EXEMPTION FROM WORKERS
'
COMPENSATIONINSURANCE
is se (This freed cot boeunpleicd irthe ocrnrit Is for one hundred doDus (Stoo)
�\
or Ins.)
I certify that 6t the paforrnarrce of to work for which this permit is Isrucd, 1 shad not
employ any person in shy mariner so as to become subject to the Workcrs'Compenucion
Laws of California. Date
"
Applicant
NOTICE TO APPLICANT: If. after making this Ccnifrcate of Exemption. you should
become subject to the Worker's Compensation provisions of the Labor Code• you must
2: forthwith
comply with such Provisions or this permit stall be deemed revoked.
D
jl CONSTRUCTION ION LENDING AGENCY
I hereby afirm that there Is a constructirm lending agency for the perfunnants of
the'k rur which this permit Is issued (sex- 3097. Civ. C.1
(.traders Name
Lender's Addreu
.
I cenlfy that I have mad this application and state that List above information is
corrtcL 1 spree to comply with 91) city and county ordinances and suite laws relating to
building eonuraclion, and hereby autbarire repmsentarives or this city to enter upon Lhc
shove -mentioned for inspection
property purposes,
y (We) agree to saw. Indemnify and keep harmless the City of Cupertino against
liabilities.
,
on judCmnu, costs and expenses which may in any way accric against smA City
in eopsequencc of the gnrteing of this permit
APP - ANT UNDERSTANDS AND WILL COMPLY WITH AL •POINT
SO CE REGU ONS.
Issued by: Date
-Re-roofs
Bignaturc of4pplicki0conuitclor
D
HAZARDOUS MATERIALS DISCLOSURE
Type Of ROOF
Will the applicam Or future building occupant stun orhandic ha ardous mascrial
as dermcd by the Cupertino Municipal Coda Chapter 9.12, and the Health and Safety
Code. Sccuon7sssz(,>7
Yea es Nu
All roofs shall be inspected prior to any roofing material being installed.
Will thc applicant or future building occupant ux equipment or devices which
If a roof is installed without first obtaining an inspection, I agree to remove
hnrardnus air conianinams as xxncd by arc Bay Area Air Quality Management
al] new materials for inspection.
strict?
❑ Yes EffNu
1 have read the harsrdrnrs materials requircmems under Chapter 6.95 of the Califor•
nia Health & SJclyCode, Sections IM5. 25533 and 25534,1 can then f the Bat ld erg
does not currently have a CnanL that It Is my msponsldlky m on occupant of the
ukcmcnis whit muatbe meL b issuatccofa Cenirratpa c ey.
Signature of Applicant Date
to slur onzcdaccnr Date
All roof coverings to be Class "$" or better