07070169 CITY OF CUPERTINO �- ` "
BUILDING DIVISION PERMIT 1����l��T�� �����T�QN: !
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BUfLD N a DD ESS: PERMIT NO.
��.i1� N PORTAL AVE TBD — TJ BE DETERMINED 07070169 �
PERMIT LSSUE DATE
R'S NAME:
1 2 �
SANITARY NO. CONTROL NO.
PHONE:
BUiLDING PERMIT [NFO
ARCHITECI7ENGiNEER:
BLDG ELECT PLUMH MECH
� 0 � 0
i p � LICENSED CONTRAC7'OR'S DECLARATION JOIJ DeSCilptlOfl
; V� I hcrc6y afGrm that I am licenacd undcr provisions of Chaptcr 9(commcncing
: Z� with Scction 7000) of Division 3 of ihc Bu�ncss and Profcssiuns Code and my liccnsc is S FDWL— T iV0 S TORY 3� 119 , GARAGE 6 2 6 '
;� y in full force and cftec�
� � ? Licensc Clazs ��• �
� � O Datc Contractor
� ARCHITECI'S DECLARATION
j a a 1 undcrs�and my plans shall bc uscd as public rccords
>yU
' u. � Licenscd Profcssional
� y � OWNER-BUILDER DECLARATION
I hcrchy alfirm �at 1 am excmpt Crom ihc Convactor's Liccnsc Law Car thc
� q o [oliowing rcason. (Scction 7(J31.5, Busincss and Profcssions Calc: Any ci�y or caunty
�,° � which rcquires a pertnit to conswct, altcr. improve, dcmolish, or rep�ir any strucmcc
�" y prior ui i�s icsuancc, alsa rcquires �hc applican� for such permit to filc a signcd stalemcnt
=?< ihat hc is liccnscd pursuant to thc p�ovisions of thc Conuactur's Liccnsc Law (Chaptcr 9 Sq. Ft. Floor Area Va uation
r H� (commencing wiih Sation 7000) ot Division 3 of �hc Busincss and Profcssions Cadc) or $ 7 0 3 913
y�� that he is uempt thc�c(rom and the bacis for ihe allegcd exemptioa Any violation o[
Secuon 7031.3 by arry applicant Cor a permit subjecu ihe applicani to a civil penalty of Number Occupancy Type
not more ihan Crvc hundred dallars (SS00). 3 1 6 2 9 � � 4��
❑ I, as owncr oC tt�e pcoperty. or my employca with wages az their solc compensation,
wilidothcwork,andiheswauceisnotint�ndcdorofferedlorsalc(Sec. Required Inspections
and Professions Cade: The Canuxtors Licence Law docs not apply to an owner of
property who builds or imQroves thercon, and who das such wark himself or through his
own employces. providcd that such improvemenLS are not imended ar a�ered Cor sata IC,
however, the building or improvement is sold wi�hin one year oC complction, the owner-
builder will have the burden of proving t6at he did no� build or improve (or purpose of
sa1cJ.
J / �I, as awner of the praperty, am exctusively contracting wi�h Gcensed conuactars w
rnnTt�uct the projea (See. 7044. Business and Professions Cade:)'The Contractnr's Li-
cense Law docs not apply to an owner of property who builds or improves t6emon, an1.
who contracts for suchQcojEe�s with a convactor(s) licensed pursuant to the Controctors
License Law. %
r' I am + . B& P C(or �his rcawn
� � ` _ Date � _ . _
- W RK 5 COMPENSATiON DECLARA170N
I hercby affirm unde� penalry of pe�jury onc of the (ollowing declarations:
❑ i hsve and will maintain a Cenificate of Consent to self-insure (or Worker's Compen-
sation, as providcd for by Section 3700 of the Labo* Code, Cor the perfortnancc of Uu
woric tor which this permit is issued.
❑ I have and will maintain Workcr's Compensation Insunnce, as �equired by Scction
3700 oC �he Labor Code, Cw the performance a( �he work for which this pem�it is iuued.
My Warker's Compensation Insunnce carticr and Policy number aze:
Cartier. Policy No.:
CERTIFICATE OF EXEMPI'[ON FROM WORKERS'
COMPENSATION INSURANCE �
(This section necd not be canplcted i( the pcnnit is for anc hundred dotlazs (5100)
ar Icss.)
1 cenify �hxt in thc performancc af thc work for which �his pertnit is issucd, 1 shall not
employ any person in an annc so �o bcco c wb'ec Worlccrs' Compcnsation
Laws of Cali[omia
Applicam �
NOTICE T'O AP CA :[, r a'kin Ihis Ccnific EzcmpGon, you should
become subject e orker's Campensauon provisions of ihe Labor Code, you must
� z foMwilh comply wi�h such provisions or this pecmit shall bc dccmcd mrokcd.
z O CONSTRUCTION LENDING AGENCY
E r � I hcicby aCfirm ihat thcre is a construction Icnding agcnry for thc perfortnancc uf .
��✓ ihc wurk for which this permit is issued (Scc. 3097, Civ. CJ
W� Q Lendcr's Namc
C,ender's Address
(� � � certi(Y �hat 1 have rcad ihis application and siaie that the above information is
w ►" cortect. I agree �o comply with all city and county onlina�u:es and state laws rclating �o
O J building conswction, and hcrcby authori�e reprcscn�ativcs of ihis ciiy to cntcr u�n thc
� W abovc-mcnuoncd property for inspccdoa purposes.
a (Wc) agrce �o save, indcmni[y and kecp harmless the Ci�y of Cupertino against
�� liabilities, judgmcnls, cosLS and expcnscs which may in any way acctuc against said City
U z in consequencc oC granting of this permit. , /�
►'� APPLICANT
� � ?�' Re-roofs �/
Sign ofA plican ontncwr Da
HAZARDOUS MATERIALS DISCLOSURE Type of F.00f
Will ihc applicant or futurc building accupant store or handlc harardaus matcrial
'efincd by ihe Cupenina Municipal Codc. Chapter 9.12, and the Hcal�h and SafMy
�. Scction25532(a)? All roofs shall be inspected prior to any roofing material being instalaed.
❑ Y� �° .
Will thc applicant or futurc building occupant usc cyaipmcnt or dcriccs which
If a roof i s installed without first obtaining an inspection, I agree to remove
emit ha•rardous air conuminan�s u dcfincd by the Bay Area Air Qualiry Managcmcni all new n iaterials for inspect.ion.
o�su����
❑ Ycs u
t havc rcad �he hvardcnu aicrials rcyuircmcn�s undcrChap�cr 6.95 o(ihc Califor-
nia Hcalth & Safct Codc, Sccuons 25505, 25533 and 25534. f undcrstand �hat iC ihc building
docs noi c t y'havc a tcnan6 that it is my responsibiliry w notify thc occupant o( the
royuirc �s wn�ch bc t prior to issuancc of a Ccnifica�c o(Occup Signature of Applicant Date
� C'� Al1 roof coverings to be Class "B" or better
nc au�horizcd cnt Da