03120121CITY OF CUPER'I'INO
BUILDING DIVISION PERMIT
f b` NTRA TOS tiINVO,RMATION ..
BUILDING ADDRESS:
NOVO CONSTRUCTION
PERMIT "03120121
OWNER'S NAME:
PERMIT ISSUE DATE
PR
E:
"-
SANITARY NO. CONTROL NO.
(650)701-1500
ARCHITECT/ENGINEER:
$UILDING PERMIT INFO
BL Y!/ B PLUMB MECH
1 d o 0
LICENSED CONTRACTOR'S DECLARATION
I hereby I licensed Chapter 9
Job Description
affirm thio am p (commencing
R under previsions ca
with Section7")of of Division 3 of NC Business and Profcwions Codc, end my liccnn is
�� /;1♦
m fullRe erfeLt.
TI--OUTERBAY
Class
License Class Contractor
Ddk CVII
TECHNOLOGIES TI ,fs� -�
00
DELL
ARCHITECTS DECLARATION
1 undcratanJ my plans shall he used ss public rccnrdx
- - ®z y
a®���
Licensed Professional
OWNER-BUILDER DECLARATION
1 hereby affirm Nat 1 am exempt from the Contractor's License Law or the
following reason. (Section 703 t.5, Business and Professions Code: Any city or county
which requires a permit in construct, alter, improve, demolish, or repair any structure
poor In its issuance. also requires the applicant for such permit to file a signed statement
that he is licensed puvwnt to the Provisions of she contractors License Law (Chamn9
- Sq. Ft. Floor Area Valuation
(commencing with Section 7") of Division 3 of the Business and Professions Code) or
that he is L accept thcmfrom and the basis far the a11,Cd exemption. Any violation of
Section 7031.5 by any applicant for a Permit subjects the applicant to a civil penalty of
r;srunmai.,N�a ..rass
3w'anIl 2ALzr00
QCCU anC Type
nm mom than five hundred dollars ($500).
P Y YP
❑ Las owner of the property, or my employees with wage as their sole compensation,
will d0 die work, and the s W[lum is not intended lir offend far sale (Sec. 7044, Business
ane Professions Cade: The Conflict... License Law docs not apply to an owner of
Required Inspections
property who builds arimpraves thercon,and who doessuch wurkhimadf or through his
own employees, provided Nat such improvements ve not intended crotTered foraale. IL
however, the building or impnnumt is said within one year of lu mplolion. the owner-
builder will hen the burden of proving Nat he did not build or improve for purpose of
n J.
1, as owner of the property, am exclusively contracting with licensed contractors to
c-hadoact the project (Sec. 7044, Business and Profrsaians Code:) The Contractor's Li-
censeLaw does not apply to an owner of property who builds or improves themon,card ,
who contracts for sur h ejects with a compounds) licensed pursuant to the Contractor.
License Law
ame m nder S.C. _ ,B&PCfsr this mason
r Dek /- U�
L WLIPRNSAT10N DECLARA'p0NIhereby
J.1/t
affirm under penally of perjury arc of a a owing declarations:
ban and will maintain a Certificate of Convent to uif-insum far Worker'sCompcn-
n, as provided for by Section 37M of the Labor Cade, for the performance of the
work for which this permit is issued.
❑ 1 have w0 will maintain Worker's Compensation Insurance. as required by Section
3700 of the labor Code, for the performance of Ne work for which this permit la issued.
My Workers Compensation Insurance Carrier and Policy number am:
Cartier: Policy No.:
CERTIFICATE OF EKEMP120N FROM WORKERS'
_
COMPENSATION INSURANCE
Cnissection wed not becomplekJ if the permit is!iron hundred dollar. ($101,
or Less.)
I certify that in the performance of the work for which this permit is issued, I shall not
employ any person in any manner an ss to become subject a the Worker.' Compensation
Laws of coliform.. Data
Applicant
NOTICE TO APPLICANT: IL after making this Certificate of Exemption, you should
become object to the Worker's Compenntion provisions of the labor Code, you most
forthwith comply with such p r visiws or this permit shall be deemed man dead.
CONSTRUCTION LENDING AGENCY
I hereby aRrm that there is a convection lending agewy for the Performance of
,
doe work for which this permit is issued (Sec. TIM, Civ. C.)
'
Leader', Name
Lender's Address
1 cenify that 1 have read this application and oak that Ne abort information is
Comet. I agree to Comply with all city and county on iewas and state laws relating to
..
building ConsWction. and hereby Cahoon mpmsenlatins of thin city to enter upon the
shove-mentionedproP
urty favi s.
purpowhich
(We) agree to saw, indemnify and keep harmless the City of Cupertino against
judgments, costs expenses
Co.kand expenses which may In any Way aLCNC against said City
a
in consequence of t c greening of this permit.
I'
APPLICA U ERSTANDS AND WILL COMPLY WITH NON-POINT
Issued b Date
y�
SOURCE E /AT10 �%
Re-roofs
Type Of ROOF '
�(� U ff�C��
Signaturc APPBCaHAZAtraccor RDOUS MATERIALS DISCLOSURE �� ate'
Will the applicam or rakrc building uccupot store or handl, herardoua maknal
or defined by the Cupertino Municipal Code. Chapter 9.12. and the Health and Safely
Cole, Sarson 25532(.)?
❑Yes AR'Y�o
All roofs shall be inspected prior to any roofing material being installed.
Will the applicant or trove., building occupant sac equipment or devices which
a roof is installed without first obtaining an inspection, I agree to remove
it havardous air contaminants as defined by the Bay Area Air Quality Management
all new materials for inspection.
. istricl?
❑Yesu
I have read the havardousmaterials requirements under Chapkr6.95 of thc Calif.,
otic, Such rou 25505.25533 and25534.1 Crucrsdmd thatifthc building
malkalthNE,
Jars not
accregaiNm,moat mei Pno ilia L oracLnieeatgo La nL
Signature of Applicant Date
All roof coverings to be Class "B" or better
g
'own,authori'rcd agent Wm