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CITY OF CUPERTINO
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BUILDING DIVISION PERMIT
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BUILDING ADDRESS:
NOVO CONSTRUCTION
PERMIT NO.
04070123
OWNER'S NAME:
PERMIT ISSUE DAIS
E:
SANITARY W' COTMOL N0.
ARCHITECT/ENGINEER:
BUILDING PERMIT INFO
BLDG ELECT PLUMB MEC"
LICENSEDCONTRd ION
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Job Descri i'olNAL
underSDECLARATION
1 kmby affirm that 1 am licensed under provisions of 9 (commencing
wimsmd 7 f)dDivision3afdc Buri es dirofessiom Code.andmylicerecis
in full tome rcen.
License s LM1tM
TI --INTERIOR REMODEL
Dam CunlrwED
to,
AR HITF.CI'SDECCAB�inIOdN
DEC L 2004
I understand my plana shall k used as PaW
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OWNER -BUILDER DECLARATION
A e
BUIL®I
I hereby affirm that I am exempt from the Contractors License Law far the
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following mason. (Section 7031.5, Business and Professions Cade: Any city art county
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which requires a permit to mnmrue, eller. improve, demolish. or repair any structure
prior m its issuance, also requires Ik applicant for such Permit o file a signed statement
Sq. Ft,. Floor Area
Va
that he is licensed pursuant to the provisions of the Contractors License Law (Chapter 9
atiOn
(commencing with Section 7000) of Division 3 of the Business and Professions Cnde) or
Nat he u exempt Notofrom and the basis far the alleged exemption. Any= of
3MIS Mlllber00
Occupancy Type
Section 7031.5 by any applicant for a permit subjects the applicant to a civil penally of
not mom Nan Ove hundred dollen Wild).
❑ I, nowner oftke properly, ormy employees with wagesu lkirsolecompensation,
Required Inspections
will do the work. and the structure is notineended W offered Russia (Sm. 7044, Business
and Professions cox: Thin Contractors License law does not apply m an owner of
property who builds or improves themon, end who does such work himsel f or through his
awn employees, provided that such improvements are not identical oronemd for sale. If.
however, the building or improvement is sold within one year of completion, the owner
builder will have the burden of proving that he did not build or improve for purpose of
sale.),
[` I. as owner of Ne property, am exclusively contracting with licensed contractors to
construct the project (Sec. 70x4, Business and Professions Cade.) The Contractor's Li-
cense law does not apply to an owner of property who Wilds or improves themon. and,
who contracts for such pmjecu with a c idoximr(s) licensed pursuant m Ne Contractor's
Law,
prim
d n exempt under Sec. B & P C far this reason
,
Owner Dam
WORKER'S COMPENSATION DECLARATION
1 hereby afRrm under Penalty of perjury one of the fallowing declarations:
have and will maintain a Certificate of Conned to self-insum for Worker's Compen-
aation, as provided for by Section 37M of the Labor Code. for tic performance of the
work for which this Permit is issued.
❑ 1 have and will maintain Workers Compensation Insurance, as required by Section
37M of the labor Code, far the performance of the work for which this permit is issued.
'
My Workers Compensation lnsumrme carrier and Policy number art:
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a ' r: Pali
_
CERTIFICATE OF EXEMPTION RKERS'
COMPENSATION INSURANCE
mils secion need not k completed if the permit is Intone hundreddollars (SIM)
or les.)
I certify that in to"a�ltdo a of the work for which this Permit is issued, ) shall not
employLU.WS(annyalpfeprs�on istgy menye(prt as tp.bemm�g�Njpcyo Ne Workers' Campemation
is, Data
NO APPLICANT: If, after m g this Certified. of Exemption, you should
b T. bject m the Workers Com .tion provisions of tie, tabor Cade, you must
forthwith comply with such prmisiaos or this permit shall k accrued invoked.
CONSTRUCTION LENDING AGENCY
1 hereby affirm that Nen is a construction lending agency for the peohmmam:c of
dm work for which this permit is issued (Sec. 3097, Civ. C.)
Lender's Name
Lender's AddmY
I certify, that 1 have read this application and sum that Ne above information is
correct. 1 agree to comply with all city and county ordinances and sum laws totaling to
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building construction, and hereby authorim inpoesenulives of this city to enter upon the
above-mentioned property for inspection purposes.
(We) agme to ave, indemnify and keep harmless the City of Cupertino against
liabilities. judgaved%costs and expenses which may in any way become against induct, y
I. consequence of the granting of this Permit.
APPLICANT UNDERSTANDS AND WILL COMPLY W`TH ALL NON -POINT
Issued by: Date
RQE R E 0 U L ONS.
Re -roofs
. Si of Applicat/C. azar Dam
HAZ RDOUS MATERIALS DISCLOSURE
Type of Roof
Will the applicant at (inure building occupanumre or handle hamrdous materia(
as defined by the Cupertino Municipal Code. Chapter 9.11, end the Health and Safely
code,0yea azss32(a)7
❑te
All roofs shall be inspected prior to any roofing material being installed.
If a roof is installed without first obtaining an inspection, I agree to removes
W01 the applicant of ummo building occupant use equipment or devices which
t ha.moubit contaminants as dclidd by the Bay Atoa Air Quality Management
all new materials for inspection.
lalrlCt7 � �
❑Yes •OINu I
11 Ihave inW the hmatdnus materials requirements under Chapter 6.95 of the Califon
ria HmIN & Safely Cox. Sections 15505.25533 end 25534.1 understand Nu if Ne building
does not curcn0y have a tenant Na it is my responsibility to notify uta occupant of the
nimmeniswhicmm1melpnarm' aofacertifieteofaet `
gignatureofApplicant Date
y All roof coverings to be Class "B" or better
r or authari'rcd age. Das