04040198CITY OF CUPERTINO
:
BUILDING DIVISION PERMIT
CONTRACTOR�INFORMATIION-'
BUILDINGADDRE9s:
222R9 TAN 7F. AVE (T-OT9)
CUPERTINO CONSTRUCTION INC
PERMIT NO04040198
OWNER'S NAME:
PERMIT LSEUE DATE
SHERMAN TU
E:
SANITARY NO. CONTROL NO.
(408)253-9000
ARCHITECTIENGINEER:
BUILDING PERMIT INFO
BLOC ELf:CT PLUMB MECH
LICENSED CONTRACTOR'S DECLARATION
"'
Job Description
p
al I am liamcd under pm of Clup¢r Y (commencing
I herby/ffirm d"":'
'am
with Scam )of Division Ser WC Businos PM'Code. and mylice„su
in ror ra I.
REVISION--IN HOUSE USE ONLY
License .N
Da mancmr
NO NEW PERMIT ISSUED/ORIG. 403030046
'Cr TION
"ARC
made and my pia 4s,11 be used u pin records
Licensed P f..i.
OWNER-BUILDER DECLARATION
y affirm Nal 1 am exempt from the Comeactofs Limnse Law for [be
fallowing mason. (Secuom B13 1.5, Business and Professions Code: Any city or county
which ".I. a permit m consuua, alter, improve, demolish, or repair any structure
prior At iu issuance, akar .I. dte aprifcam far men permit m El ... igned.mumenl
of the, Comtacross U.. Law (Chapter 9
Sq. Ft. Floor Area
Valuatio$107
thin he uUmnred pumnantmtnc proAsimm
(commencing with Section 70111 Of Division 3 of the Business and Pmr.ssiam Coda) err
exempt therefrom and the uss for un, Alleged exemption. Any violadon of
Nat he u exb
APN Number
Occupancy Type
Section 7051.5 by airy applieant far a permit subjects the aPPII ant In a civil penalty of
net mom Nan Eve hundred dollars ($500).
35701017.00 -
Lu MmaroflW
0 property,m
sAc.7W.eminess
-
Required Inspections
fm n4(sec. 7014,
I.. timmuluwithwaguen.ah
Owner
License law deo riot apply if w.,o•
AndPrtowmleandthesuucmmistiar', icons Lav,itd
ane 0ns Code: Tbp Cm
rt his
en,wh tine om is
progenywhobuildsorimpmms thereon,andwho dosssuchwork hinar
edthrough
awnemployes,providedthat such improvementsam not intendedx mfered fm tile. If.
however, the Wilding or improvement is sold within one yeti of completion, the owner-
builder will have Ne burden of proving that he did not Wild or improve for purpose of
ala.).
dwly connecting with licensed contractors m
❑I: as Owner of the propcny, am uusi
Pmreuions Code:) The Contricmr's Li-
CSmtmct Ne pmjcct (Sce. 7064. Business and
who Wilds or improv thereon, and,
made law does nm apply m an owner of property
who convects for such pmjcm with a corm cmr(s) lic<med pursuant tote Contractor's
O
License law.
B P C,11far
G l em cacm S .
,N,isccm[s000n
e
Owner Date �
\
WOR OMPENSAT NDECLARATION�``'�!!
V
1 hereby oder penalty of perjury one of the following RdRltlam:
hoe and will maintain a Certificate Of Consent to self insure for WorkersCompen-
sation, As provided for by Section 3700 of de Iatim Coda. for um perfornence, of 0e
work far which this permit is issued.
0 1 haw and will maintain Worrier's Compemadon Wursnce, As Acquired by Section
3700 of de, LAW, Code. (ror the per(armanee of to work for which Nu permit Is issued.
My Worker's Compensation Insurance carrier and Policy number mo:
Carrier. Policy No.:
CERTIFICATE OF EXEMPTION FROM WORKERS
COMPENSATION INSURANCE
(Thuseaiah reed not W compIcAd iflive permll is fm one hundred dollen (5100)
or Icer)
I cemfy duet in the Pcrfmmancc of the work for which this permit is issued. I shall not
employ any person in any manner so As An become subject to the Workers Compensadmn
Laws Of California. Data
Applicant
NOTICE TO APPLICANT: If, after making this Certificate of Exemption, you should
become $Object 10 the Worker's Compcmetion pmvisiom of the Labor Cock, you mom
forthwith comply with such provisions Or this Permit shall W deemed rtrvoked.
CONSTRUCTION LENDING AGENCY
I hereby affirm that them is a construction lending agency for the perrmrmarm of
de ..,it fur which Nis permit is issued (Sec. 3097. Cie Q
Lendcss Nam.
_
Lender's Address
I canary Nn I haw read this application and sate that the aWw information is
coma I agree to comply with LI city and county ardimtaes and state laws miming an
building construction , and hereby autWrim Acpmeematiws of this city to enter upon the
aWvc mentioned proPcrty for impecdon purposes.
(We) agrt to lam indemnify and keep hsrmlass the City of Cupertino gaiml
Iiabilitica judgments, coats and expenses which may in any way secne against said City
Y in consequence of the graining of this permit.
LICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT
Issued by: Date
ULATIONS.
e-roofs
Type of Roof
I
signetum a n ror
HAZARDOUS ATERIAIS DISCLOSURE
Will tiro applicant err fu nc h ?ding occupant marc or handle hammous material
As defncd by Me Cupertino Mums 1 Code. Cbaper 9.12, and the Health and Safety
Cme,Section 25s32AY? %
All roofs shall be inspected prior to any roofing material being installed.
❑Yea r)�J^m
If a roof is installed without firs[ obtaining an inspection, I agree to remove
will the applicant or forum Wilding aavpant use equipment er dcviaa which
I hazardous air contaminants u Goad by Ne Bay Area Air Quality Management
all new materials for inspection.
,strict?
OYcs u
I have mm the Wrardousmaterialsmquimmen s under Chapmr 6.95 oldie Califor.
ria Health&Sarety Code.Sxuom25505,255J7�SiSNr.l undctsmnd dhu if Ne Wilding
dao not rally haw a ¢nano Nn iI u my ms miry m nmfry the occupant nr the
ISignature
Z. tris Wmet poor mi fa OfCeemp$Ocy.
ofApplicant Date
��
roof coverings to be Class "B" or better
wrier era and spent Data'All