05040055CITY OF CUPERTINO*"``"
INFORMATIQN R
BUILDING DIVISION PERMIT
CONTRACTOR
BUILDING ADDRESS:
4(;0 RilsR Rn
BERG & BERG
PERMIT"5040055
ER'S NAME:
PERMIT ISSUE DATE
BERG & BER
1 2
ONE:
SANITARY CONTROL NO.
ARCHITECT/ENGINEER:
BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
LICENSED CONTRACTOR'S DECLARATION
Job Description
1 hereby affirm that 1 am limnsea under provisions of Chapter 9 (commencing
wish Section 700Q.f Division 3.f the Busincssand limfcssiom Code, and my license is
in full force and effect.
TI--SUPPORT OF 3 UNITS ON (E) PLATFORM
License Class Lk. g
Dam. Comsacmr
ARCHITECTS DECLARATION
I understand my plans shall be used as public records
Licensed Pmfessi... I
OWNER-BUILDER DECLARATION
I hereby affirm that I am exempt from the Contractor's License law for the
following reason. (Section 7031.5, Business and Professions Code: Any city or county
which requires a Permit to construct, alter. improve, demolish, or repair any structure
prior to its issuance. also requires the applicant for such Permit in file a signed summcnt
9
Sq. Ft. Floor Area
Valuation
that he is licensed pursuanto the provisions of IN Comm on's Umemse Law (Chapter
(commencing with Section 70007 of Division 3 of the Business and Professions Code) in
that he is cxcmpt th rctmin and the basis for the alleged Gumption. Any violation of
35�ie100
Occupancy Type
Section 7031.5 by any applicant for a permit ubjecu Ne appbicanuo a civil penalty of
not more Nan fisc hundred dollars (S5OB).
❑ 1, u owner ortlie pmpmy. a my employes wish wages u Chir sok compenssdan,
Required Inspections
q p
oral ao she wmrk sons theawcmreis nntintana<a nrorterea reraae (sK. yDaa, easi�a
and ProfeCode: The Contmcmrs License law does oat apply m an owner of
ssion
property who builds or improves thereon, and whodoca such work himself or through his
own employees, provided that such tmprovemenu art not intended Orarterad for sale. If,
h..,. she building or improvement is sold within one year of completion. the owner-
builder ori have the humen of proving Nn be did not build or improve for purpose of
sale.).
h as owner of the property, am exclusively contracting wish licensed contractors no
construct the pmject (Sec. 704a. Business and Profession Code:) The Common's Li-
ccme Law docs not apply m an owner of property who builds or improves Overarm, and,
f1
who contracts for such projects with a contractor(s) licensed pursuant to the Contractors
V (�
License Law.
m cacm t rode 5, . B k P C forthisanon
v
ter Dam
:,in
'S PE S DECLARATION
1 hereby intounder perry perjury a of the following declarations:
I have and wi maintain a Certificate of Consent o self-insumfor Worker's Compen-
sation, as provided for by Section 37W of she labor Code, for lie Performance of the
work for which this permit is issued.
El 1 have and will maintain Worker's Compensation In... as required by Secfion
37W of the labor Code, for the performance of the work for which this permit is issued.
My Worker's Compensation Insurance carrier and Policy number am:
Cartier. Policy No.:
,
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(Thu semism need nosh mmplemd ifthe permit Is Barone hundred dollars ($10))
or kss.)
I certify that in arc performance of the work for which Nis Permit is issued. I shall not
-
cmployanypersoninanymanncr w as in become subjectath-
LawsrfCalifor' M
Applicant
NOTICE TO PPLI : If. after gotta m Exemption, you should
themed revoke you most
oYtirn dr
beenino Compensation
hpoCOmpe
crit bell
� foMwish comply wr sucM1 pmviilnm or Ni omit shall haamcd revoked.
LENDING AGENCY
OutCONSTRUCTION
1Aunw affirm there is•ed(Sec.3 Lending agency (car Nc perfurmence of
> the work fur which this perms u issues (Sec. 709'!. Civ. C.)
Pe
zlender's Name
Z Lenders Addsras
Z) 1 certify that 1 have mad this application and stile Nat the above information is
correct. I agree on comply with all city and county ordinances and sou laws relating M
building construction, and hereby authonce mpracntatives of this city to enter upon tic
above-mentioned property for impaction purposes.
2. (We-) agree to save, indemnify and keep harm) am City of Curcm.0 against
liabilities, judgments.costsand expen swhic mayany way accme against evict City
e fthegn 'ng oft s ami
NDERS ND AN W PLY WITH ALL NONiP01
Issued by: Date
U TIRe-roofs
4APPLI
Pl ca on o DemAl ARDOrS ATERI LS DISCLOSURE
Type of Roof
e applicant or fuw 'Idirg i amistmo or hark lointmous material
thr Cupertino Mu 1 Code. Chapter 9.12. and f Heabar and Safety
e. Scotian25532(.)?
All roofs shall be inspected prior to any roofing material being installed.
Yee Nu
If a roof is installed without first obtaining an inspection, I agree [o remove
Will the applicant or future building Occupant use: equipment or devices which
mit hil.dnus air comentnan dcfincd by Ne- Bay Ana Air Quality Management
all new materials for inspection.
Disaiet?
❑Ycs Nu
I have rad the havard... m.crish requimmenu order Chapter 6.95 of the Celifnr-
rioHcalthk5 c Code.Sadom 5.255 d2553d.1 understar thazif Ne- Willing
tiara not c w a sen Na a amobility us notify the occupant of the
a
mgomme ube et o cennanieareofaevanryDS.
Signature of Applicant Date
All roof coverings to be Class "B" or better
owner r s ascot Da