04010046 CITY OF CUPERTINO
BUILDING DIVISION PERMIT CONTRACTOR INFORMATION t
BUILDING ADDRESS: PERMIT NO04010046
04 010 04 6
O0429 STEVgNg GREEK BT�VE)
WNER'S NAME: PERMITISSUE DATE
NE: SANITARY A07 CONTROL NO.
ARCHITEC(ENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
:Op LICENSED CONTRACTOR'S DECLARATION
e V F 1 herchy affirm that 1 em licensed under provisions of Chapter 9(commencing Job Description ` mss s.
< `uj with Scnipn](N10)nf DivixianJ of�M1CB amid Profession Codc,end my licenuis a_®i C\6'f
^ d infullera�aand,drfie IV �`g ® �®
uan c kd o ADD 3 CIRCUTS & POWER TO A/C tb
�0 - - G° dC1 CONTRACTOR: HOWELL ELECTRIC JU
dq ARCHITECT ARATION C �']
D moo. 1 understand my plans shall M esu as puM1lic rccnNs nf�� 001
JyU (F
30; Licensed Professional 8014 1
'pX OWNER-BUILDER DECLARATION {� ®,
E e E I hereby affirm the 1 1. exempt from the Contractor's e:Any
Law for the NG
OO which re mesa Permit 7011.5,Business and improve,
demolish,
Code:Any city or county - VVV
k m which requires a .also re camtrucL eller,improve,h permik t file
repair any strumum
prions itscensed pursuant to
theres prevision Of to
SucContrarmiuoicense ned Law(Chapter
FF ex (commencingwJpurction7 h)ofDivinnen OFtheStracmr'sniccnselaw(Chapmr9 Sq.F[. Floor Area Valuat 000
Y S (hat he is commencing with Suction 7")of DivisionJnf NC Business and Pmfessians Code)or
Nal he is exempt therefrom and the basis for the alleged exemption.Any violaftion of
Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of APN Number Occupancy
nos more Nan five hundred dollan($500). P y 'J pe
❑1,is..Or of the property,or my employees with wages as their sole compensation, 3 1646094 . 00
will do the work,and thestmcmm is not intended or offered for sale(Sec.7D,,L Business -
and Professions Code:The Contractorw
's License Law does nor apply la an Oaer of Required Inspections
property who buildaor improves thereon.and who does such work himself or through his
Own employees,provided that such improvements arc not intended or offered formic.If,
however.the building or improvement is sold within one Your of completion,the owner,
builder will have the burden of proving Nm he did not build or improve for purpose of
net. .
❑1,as owner of the property.am exclusively contracting with licensed contractors to
contract the pmjmt(Sec.7044,Business and Professions Cotler)The Conuacum's Lt.
came law does not apply to an owner of propeny who builds or improves Neuron,and
who conoacls for such projects with a eonuacmr(s)licensed pursuant o dm COOV61Or3
License Law.
❑I am exempt under Sec. ,BAPCfor this rcman
Owner Date
7wkWORKER'S COMPENSATION DECLARATION
1 hereby aBbm under perally of perjury one of the following dcolanrions:
aw and will maintain a Certificate of Commit_o`"n -insure for Walkers Compcn-
m provided for by Section 377 of the labor Code,for the Performance of the
for which this permit is issued.
an and will maintain Worker's Compensation Insurance,as required by Section
f the labor Code,for Ne performance of the work for which this permit is issued.orker's/Cy,Q��rim$y'o insurance artier and Policy numberraim: C/fA/ KK. � Palic 1W PF b` 7
CERTIFICATE OF E%EM 0 MWORKERS'
COMPENSATION SURANCE
IThinuctitm need not ba completed if the Permit is foronc hundred dollars(51(1(1)
or Ices.)
1 certify Nat in the performance of the work for which Nis Permit is quoted,l shall not
employ any person in any manner an,as to become subject o the Workerr ComPcmalion -
LawsofCithfurrim.Dam
Applicant
NOTICE TO APPLICANT:If,after..king this Ccuricam of Exemption,you should
become suhjea to the Worker's Compensation provisions of the Lehor Code,you must -
.JO forthwith comply with such novisirms or Its Permit mall be deemed revoked.
z y CONSTRUCTION LENDING AGENCY
E" I hereby affirm that Nem is a consWctinn lending agency for the Performance of
lYi
to work for which Nis permit is issued(Sec.3097,Civ.C.)
44 end
A Lenders Name
a v2 Lender's Address -
U O 1 certify that I haw read this application and stake that the shove information is
(y F coned 1 agree in comply with all city and county ordinances and state laws relating to _
O U building construction,and herchy authorixe reposentarins of our city to enter upon the
W, ahon-mentioned property for lmpceian puRm.sea
W (We)agree to save,indcminfy and keep harmless the City or Cupertino against /
iF„ fq Iiabiliuesjudgments.costs and expenses which may in anywayac me against mid City
in conuqucncc of c graining of This permit. D
APPLICANT U DERSTANOS AND WILL COMPLY WIT LL NON-POINT Issued by:3 Date
SOURCfI: AT Nom/
- ��e �y Re-roofs
Si of Applicant/Comr¢mr Dam
HAZARDOUS MATERIALS DISCLOSURE Type of Roof.
Will the applicant or future building Occupant store or handle hazardous material
as defined by the Cupertino MunicipalCode.Chapter 9.12.and des Holds and Safety
Code,Section 25532(x)+ . All roofs shall be inspected prior to any roofing material being installed.
❑Yet <No
Will the applicant or future building occupant use equipment or devices which -If a roof is installed without first obtaining an inspection,I agree to remove
u Will
air conmminanu as deared by the Bay Arca Air Quality Management all new materials for inspection.
❑Yes Jtl�'n
I ham read the havardousmamrials nequircmems under Chapu:r6.95 of Ne Califor-
nia He.lth ffi Safety Code,Semonk 25505,35533 and 25534.1 Underwood his if the luilding
dura not lucent he a tenant.Net it is my rcsponsihility m nod j the mcupans of Nc
rmptim.cnts ieh ust .p" mismaneeof.Cnnlreakeaeupanoy. Signature ofApplieant Date
30 All roof coverings to be Class"B" or better
OsLn r ser a omcd agent Data