03120079 CITY OF CUPER'I'INO ;+' 52 ,i=.kwa,`as;§r. w�hArra
BUILDING DIVISION PERMIT ,CONT"C,"TOR INFORMATION
BUILDING ADDRESS: PERMIT NO03120079
OWNER'S NAME: PERMIT ISSUE DATE
LAP LE
I E: SANITARY N0. '11CONTROL N0.
ARCHITECT/ENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
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LICENSED CONTRACTOR
under S DECLARATION Job Description
[[mp I hereby affirm Nal i am licensed under provisions ors Code. 9(commencingsis P
e?W With llforcn7(deffef0ivision3o(NC Business and Pmfessieni Code.and my license is
m ren rnme am effect. ALTERATION
Z jIj Z Lleenac Class tic e
coo Da¢ Contractor
',S`y ARCHITECTS DECLARATION
y d
nI understand my plans shall heed as public records
JU used
u.
T G Licensed Pmressional
g OWNER-BUILDER DECLARATION
ap 1 herehy at@n that I am exempt from the Co oraemr's License Law fur the
p O following mann.Section 70313.Business and Professions Chi Any city or county
K m 9� which requires a Permit Ire construct,alter.improve,demolish,or repair any Someone
e2} prior to its issuance.also requires the applicant ror such Fenno to G lc a Signed Statement
< that he is licensed pursuant 10 the provitions Or the Contractor's License Law(Chapter 9 Sq. FL Floor Area Valuation
(corn mencing with Sectio 70XB of Division 3 of the Business and Professions Code)or
Nat he is exempt therefrom and Ne basis for but alleged exemption.Any violation of
Section 7031.5 by any applicant for a Permit subjects the applicant to a civil penalty of 3 BtTN710io ber0 0 Occupancy Type
not more man five hundred dollars 0500). P Y YP
❑1,vs owner of the pmpcvy,or my employe=with wags AS Meir sole compensation.
will do He work,and the suucmm is not intended or offend for sale(Sec.IDM,Business
and Premations Code:The Committee's License Law does not apply to an owner of Required Inspections
properly who bullas or improves thereon,and who does such work himself or through his
own employees,provided that uch improvements ase not intended or offered for sale.IL
however.illbandugorimpmaememtis soldwithindid not year of orproedon.theowner- ��ok 0
builder will Mvs the burden w proving mat M1e did not Wild or impmse for Popo n of
sale.).
❑1,as owner of me property,am eselusively contacting wish licensed convectors to
NALED
common the pmjcct(Sec.7014.Business and Professions Codc)The Contractor's Li
Sense law docs not pply to An owner of property who Wilda or improves unman.and JUN 0 9 2004
who contracts for such projects with a ccom actor(s)licensed pursuant m the Conusetofs -
Licemse law.
❑lam eae 'under SCc. DUAJAata
h Pl CCffoorr this season r�{.�/� 1
O fie WORKER'S COMPENSATION DEC s�l I ION l ®A S ®I
1 hereby Arlan under Penalty of perjury one of the following declarations: °°��
1 have and will maintain a Certificate of Covent to self-insum for Worker's Compere
satinn,AS Provided for by Section 37M of she IaWr Code.for ase Pedomo em of the
work for which this Permit is issued.
0 1 have and will maintain Workers Compensation Insurance,AS required by Section
37W of the labor Codc,for the performance of the work for which this permit is issued.
My Worker's Compensation Insumnm carrier and Policy number an:
Cartier. Policy N.,
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(This section,seed mol be complemd if the Ixrmit is for one hundred dollars(g101B
m Ices)
I certify that in the performance of the work for which this term it is im ucd,I shall not
employ any Person in any manner so as to become subject o the Workers'Compensation
Laws of California.Date
Applicant
NOTICE TO APPLICANT:If.after making this Cemirieam of Esenption,you should
Became subject to the Worker's Comperchnion provisions of the Labor Code.you muv
.J O forthwith comply with ouch provisions or this permit shall be deemed naked.
CONSTRUCTION LENDING AGENCY
j-. l hemby affirm Oat them is a construction lending agency for she performance of
ase work for which this permit is issued(Sec.3117,Civ.C.)
I+1 Q Lender's Name
? ,z Under's Address
U O 1 ccnify Oat I have read this application and sure that the above information is
D. F correcL I agree to comply with all city And county ordinances and sum laws relating to .
U building concoction.and hereby authodm mpresenutivu of this city to Inner upon the
m
r C above- entioned property far inspection proposesrss pe
(We)agree tm save,indemnify and keep hamlethe City of Cupertino against
rn Iiabi lnm
'tics, costs and ex pees which may in any way aece against mid Ci ly
U z in consequence of the granting of this Permit. ///�
APPLICANT UNDERSTANDS AND WILL COMPLY ITH ALL NON-POINT Issued by: Date I
SOURC LATIONS.
Re-roofs
nawre of A,if nvcatt recur Date
HAZARDOUS MATERIALS DISCLOSU99FF�� ���9 Type of Roof
Will the applicant future building occupant store or bandkyF�ardous ro enol
IS,dented by IW Cupertino Municipal Code.Chapter 9.12.and me Health and Safely
Code.Section 25532(x)7 All roofs shall be inspected prior to any roofing material being installed.
Y=
Will the aPPlimm or furore building occupant use equipment or dcvic=which
If a roof is installed without first obtaining an inspection,I agree to remove
4 hamomms air comaminants as dcOmcd by the Bay Arca Air Quality Management
District? al I new materials for inspection.
Q Yes fXNp
I have mad the WraNnus materials requirements under Chapter 6.95 of Oe Cal for,
nia H.Il 2KSafcty COM.Scctiom25505.25533and25534.1undcrsund Owifthe Wilding
die not curtentiy have a¢nam.Nat it is my m."itshility m artily tbe oecupan orthl
myuiaenemawhimnusrbemmprorwissu mor clniElanenrOClupanly Signature of Applicant Date
A L2 Owaumonredagen, t ,te All roof coverings to be Class "B" or better