05030109 CITY OF CUPERTINO a* x '. '%�' "`•'�" "'" °crnv ,c'
BUILDING DIVISION PI&IT CdN�RA,,, TQRINF�O T101
P.No-a��b:..'w0"h, t r• s,ti w i° eTfr. .,s lea�^�
BUILDING ADDRESS: PERMIT NO05030109 5030109
OWNER'S NAME: PERMIT ISSUE DATE
P ONE: SANITARY 0. 96N
CHnECr/ENGINEER: roe ^BUILDING PERMIT INFO
BLDG /qp1' 1ELECT PLUMB MECH
r in, O 0
o o LICENSED CONTRACTOR'S DECLARATION
1 hereby aM m dut 1 am 14es
ocd under provisions of Cbepur 9(Commuting Job Description
with Bollors 7IXM))of Divioien 3efde Butimsssnd Pmfesdmu Cedomm!mylkrncis
Licenlsenl�"deHeC Lie. SIGN--MONUMENT W/ELECT. .f ' � ;' _•*i'
Dete
ARCHITECTS DECLARATION
? 1 understand my plans shall he used as public maned,
550 Licensed Professional
Oat I am exempt
from
DECLARATION
0 I hereby anew that 11. taempt from tine Contractors License law for the
p O fallowing Ruda.(Section 71013,Business and a Cale:Any city or cooly
$9 which requires pewit to construct titer,Improve.
ve,dermumnluh,or repair.y swetuw
prior to its Issue..,also requhs,ik applicant retouch permit to rile a signed sutement
gg That he a licensed pursuant in the provision or ft Contractor's Lcenselaw(CMpu:s9 Sq.F[.Floor Area Valuation
$ (commencing with Section 700E)of Division 7 of the Business and Proreadoes Code)On
that he is exempt therefrom and the basis for the alleged exemption.Any vioWiun or
Section 703 LS by any appliam for a pewit subjects the applicant m a civil Pemlty of 31kPN99II 0Cr0 0 Occupancy Type
not mom than five hundred dollen(S500).
❑1,asowner of tie property,or my employees with wage u 0heb.le compemadon,
will do the wmk.aMshe awemse I...,uncrtied coffered rWWC(See 7044.BLLDIWs Required Inspections
and Professions Code:The Contractor's License law don not apply to an owner of q p
property who bili Ido ori mproees themon.and who does such work himself or through his
own employees,provided thetsuch Improvements arc not Intended oroQened roraale.IL
however.the building or Wp....t is sold within mu year of crmpl.b...the owne,-
builder will have the burden of proving that M did al build or improv for purpose of
sale.).
1.as owner of the property,am exclusively contracting with licensed Contractors m
comtrocl the project(See.7044.Business and Professions Cede:)The Commemes Li-
rase law does Out apply to an owner of property who builds.improv CheRu.and,
who contracts for such projeM with aconuactor(s)licensed puneant to the Conuaelo's
License law,
13 Is aem0. ntler Sec .B k PC for this=on
Owner Date it3-01-b
WORICEIVS COMPENSATION DECLARATION
1 hereby solve under Penalty of Perjury ane of the following declardbom
haw end will mmmam•CeNficate of Consent Rself-insum for Workers Compen-
Iras provided for by Section 7700 of UR Labor Code.fm tie perfowenme of the
for which this pcmit is issued,
❑1 ha-;e and will maintain Workers Compemailon Insurance,as required by Section
3700 of the labor Code.for the performance or the work for which this pewit is Issued.
My Workers Compmadon Toren Cartier and Policy number are:
Cartier. Policy NO.:
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(Thu section need nottecoetpleted lithe permit Is ram hundred dollars(SIM)
or less.)
1 cenify that In the performence of the work for which this Wmit is issued.l shall net
employ anyprson in ymanror m ome lmctmtbe Wmkcrr CompeasNen
Tawe or calVC.M. •�
NOTICE TO APPLICANT,W,after making this Cenifinte of Exemption,you should
become subject to the Worker's Compcasatlon provisions of the Labor Code,you mum
.,
forthwith comply with.ch provisions or this permit Mall be deemed revoked.
'Zti'O CONSTRUCTION LENDING AGENCY
[—i Thereby afErm that there Is.omuuucdon lending agency for she,performance of
CYi r7 the work for which this permit Is issued(Sec.3097,Cie C.)
W�0 Lenders Name
lander,Add=
V 0 1 certify that 1 haw sued this application and mass that the above information is
Lia E correct.I agree to Comply with all city and county ordinances and sum laws relating te
0 building construction,and hereby authodw reprommURiv or this city to ranter upon Che
W shove-mentioned property for inspection purposes.
gy (We)agree m tow,tndcmnify and kap harmless the City of Cupertino against
CA liabilities.judgments,costs and expenses which may in ley soy scrne against said City �—
fJ in consequence of the granting of this pemit. /�APPLICA UNDERSTAND ND WILL COMPLY WITH ALL NON-POINT Issued by: Dater—?! —a
SOURCE R LATI Ng.
L�;—,D —a Re-roofs
Signature or ApplicanpConsuctor Dau
HAZARDOUS MATERIALS DISCLOSURE Type of Roof
WIII the applicant or fumes building occupant more or handle havardous material
as de0ned by the Cupertino Municipal Code.Chapter 9.13.and the Health and Safety
Code,QYG=9332(a)7 /Ne All roofs shall be inspected prior to any roofing material being installed.
Will Ile applicant of Puu'mtuR building MupauR use ronlpment or devices which If a roof is installed without first obtaining an inspection,I agree to remove
'It haeardois air contamimnu as dcrined by the Bay Area Air Gustily Muagmmcni all new materials for inspection.
icl7
❑Yes No
I have Rad the haasAousmaterials Rquieme"u under Chapter 6.950(the Califor-
niaxrah"Safetycode.Seetims255O5.25533 and 25534.1 understand ewlfthc building
dao ndl Cortmn y haw a tens 4 Nm It u my reapomihiliiy to notify Chum acuput of the
rtyuiRmc/. heti m�tm be pnertol,aaan.nracmnillm.mnra.Conry. Signature of Applicant Date
����;I-T�
iutherisd age. All roof coverings to be Class°$°or better
OwnerDate