00060066 CITY OF CUPERTINO
non,urnc nrvtsw` PEPMIT CONTRACTOR INFORMATION:
7 Pin
BUILDING ADDRESS I9RMi'INO.
OWNER'S NAME. APPLICATION SUIT DATE
PIiO � �D � SANITARY NO. CONltUh NO.
O.. RCHITECT/ENGhYEER, HUILDING PERMIT'INFOHLDG ELECT PLUMB MECII
S
4' LIC17 SED CUN'rRACIOR'S DECLARNHON' RDD I T I ON 12Yob 99kk:FjTLon
Z ;m; 1 luumy affirm than I ren licensed under provisions of Chapter 9lcommencing
�_t0 mina fallruored effect. on3oRhc Rosiness and l'rnresi,ns C,de, dintliansc /�
a m ac Is In full lm,and cflmt. ;7 O /
z z c 6 License Class Lic,a_
re 3 y Umc Comn¢n,r
t- O • ARCH ITECT'S ,o,um RATION �� ® _
nndttxV:nA my plans xb:,11 be u,eJ DECLARATION
TION,
et
w i O C Licensed Prolisaimml
a.%o OWNER BUILDER DECLARATION
w_w I hereby alTrm that 1 am exempt from the Commaor's Lwme taw for the' v
1-=< following ry ,.(Senion'/03L5,E Qex fid Prom ns Cale:Any Illy ar Linty
EFS worn p bin .Mp I IUh ,r y., cure :, t
to . pr'or, , I... hr the pnnc tl np .t1 II a.i$ d.rwmmi -
a. that he en d purrome,odre provision,of tire c it ..r,1 Law(Chapmr9 Sy. FCFloorArea Valuation'
(rommencing with Section](XX))of Division 3 of the Business and Pofes.i,ns Code)
or that he i,mempt therefrom and the basis for the alleged exemption.Any violation 4 00
of Section 7031.5 by any applicant for a pemat subjecte the app)icam,o a civil penalty
ofoo,more than too hindreddollan($5M,). A um er Occupancy Type
D La, -ot nhepmpnnyo my employee win,wage,alhei P oole anmponswion.
the
1-3
will ne mu work.and the,rucmre is not ctor's of er,tiered for role apply
]tact.
Raciness and I'mfnsinm Gdr.'Ihc Contractor's Lieensl I.,w n,KS not.ppb m an. 102 — P I E 9wred Inspections
orr m pmperty Who builds fir impmre,desmon•and whn Joe,such work himself
through his own employees.pmvided that such improvements are not intended or 103 — UFE R
offered for gam.if,howccr.In,building n,improvaneat is sold within one yen,of
mnnplelinn.menwic,.nuilde,w.11luteme molcoofprovb,g than redid nm build or 104 — REBAR
pmsc for purpose or sale.)
D1.as owner of me property,amesaha.ely contracting with noosed commemr,to, 105 — ANCHOR BOLTS
Liconstruct the Me,eet(See.]fIM.Buame„and Professions Code:)The Contractor's 106 — SEWER 8 WATER
cense Law does not apply to an owner of pmisery who build,Lir improves menton.
and wl,o.,ohne),for.00h roc., ire.comic„„(.)teemed pllrsuaal me 202 — UNDERFLOOR PLUMBING
Cnmrmlor'.c Liccn,e Law.
01,.1„exolnpl,n,J,,Se,. .e m P C f..mi,reason 203 — UNDERFLOOR MECHANICAL
Owner Date 204 — UNDERFLOOR FRAME
WORK17R'S COMPENSY]ON DECLARY ION 205 — UNDERFLOOR INSULATION
Ihcreby affim,under penally of perjary one„ft he follawingdeemradon, 301 — ROUGH PLUMBING
I ❑ have and will nminmin a ConiOome nl Coosen, m .n1'.inurm for W..ker',
e.a,wh,mh,n, a, provided for by sxw —
,ion 3]00 of me Labor code, lot die 302 TUB & OR SHOWER
ermrmanceorthe work for which this Permit isissued. 303 — ROUGH MECHANICAL
❑1have and will maintain Wo,kersCompen,mimInsurance.asme iredbySection 304 — ROUGH ELECTRICAL
3]1X1 of the Labor Cada 1pe
'or the ,f amumve or the wn k for which dr,permit in
,.ed.My W..ken.Compen,wion la,.rance carder and poliioy urnmer am 305 — FRAME
Canf1en PolieyN"a 306 — HOLDOWNS
CERTIFICATION OP EKEMIsnON FROM WORKERS'
COMPENSATION INSURANCE 307 — INSULATION
(Thi,.ochonnevil hot lN rmplemdinnepepni,i,for ore hundred dollars 308 — SHEETROCK
($11X))or las,.)
1 emus masa me porn„moo«or mo work for which his panni)is mr,d.1 309 — EXTERIOR LATH
shall no,employ any person in any manner so a,to become subject to the Workers' 310 — INTERIOR LATH
Cmit,nxmion Laws of Coliform..Date
Applicant 311 — SCRATCH COAT
NOTICE TO APPLICANT:If atter making,hi,Cenificme of Exemption.you.should
necome,rbjecnmare W,ke,,Co,11,,,unon proorn„Ilbe L.nm Code,you m„x1 313 — ROOF NAIL
Q 'Z' Imili hat 1,with suis pmvisinnc or Ilii,pcnnin,ball heJcmneJ revokal.
Z 501 — FINAL ELECTRICAL ENERGY
y ChatthemivaRUCTION ructionNGAGENCY 502 — FINAL PLUMBING ENERGY '
7 Ihcreor ahm„his them iss construction lending agency for the pcofomunee
of,he wed for which this pcnni,is isaueJ ISw,lfq].Civ.C.)
y p IxnJcr'sNutne 503 — FINAL MECHRNICAL ENERGY
5 Y Lender,A,IJres` 504 — FINAL BUILDING ENERGY
U O' 1eertilyman1have roadIn,a,Brea).....ndam,chit mern„veinfnnanniol,i, 505 — FINAL ELECTRICAL
Ls F, correct.I agree m comply with all coy and coan,y oNinances and,tate law,retaling
O U to Wilding construction,and hereby pithourize reprewoutivescifflak city to encru,ser 506 — GAS TEST
�, s7 me alwvomentioned property fur inspection purposes.
S (We)agreemsave.indemnify and keep nnrmlcss,he City of Cupertino again.,
rn Inmirnic,.jun' ,neoto,
l,eo ,a ul expense,which m —
may in any way seems,against smd 507 FINAL PLUMBING
U .Z. City in e„dx«laenee onbe g,amiog onnlx penldl.
SOURCANT UDRSTANDS AND WILL COMPLY WITH ALL NON-POINT Issued bUTIONS. y: `5@8 INAL MECHANICAL Date ,— z6 --V(�
'171
Signature ofnpplicanvC,ntmctor Date Re-roofs 510 — FINAL PLANNING
HAZARDOUS MATERIALS DISCLOSURE
Wiume applmam or Rome buildirg meapnm,mm or handle Maaamotoruamt .l Type of Roof 514 — FINAL PUBLIC WORKS
ns defined by he C.pertlno Mnnlcipul Co.],.Chllplcr 9.12,and the lEalm:red S:de,y
Code.Section 25532(,)!
Yea 0 N All roofs shall be inspected prior to any rooting material being installed.
wnitheapplicantorfuturebuildingoccupan,aKeaaipmentordexicc%which If a roof is installed without first obtaining an inspection, I agree to remove
emit haerolnm air aomainumns ax defined by me nay Area Air Quality M:magemem
,rshury all new materials for inspection. Applicant understands and will comply with
D Yes ElNo all nun-point source regulations.
1 hove mad the Minot,.,material, 'Imams rade,Cramer ops of the
Califamia HmIt h K Safety Coil 551 25533 and 25531.1 understand that
if the WilJinB does mac bat n ism miliv tonotify,be
time �`ne tmin mI res certifi roof
0,Crpa".. Signature of Applicant Date _
r, ,
ow ror„amodrae a fit no ALO QQ All roof coverings to be Class "B” or better
OFFICE