05030102 CITY OFCUPERTINO +"*
BUILDING DIVISION PERMIT iCQNTRAGT0R-1NRU, AT,tfJN
BUILDING ADDRESS: PERMIT N0.
05030102
OWNER'S NAME: PERMIT ISSUE DATE
E: SANITARY tftOL NO.
ARCHITEC 71ENGINEER: BUILDING PERMIT INFO
BLDG ELECT O l� PLUMS MECH
O O
3Cp LICENSED CONTRACTOR'S DECLARATION IObDeSCrI Description
di 1 bunchy affirm that I am licensed under provisions of Chapter 9(commencing P
with Section 70110)of Division 3af the Business and Pmfruimu Code,and my license is
in full to=and elRm.
n Line. Ci Lk.g y TI-CEILING UPGRADE/BATHRMS
Data ca. amoa ELECTRICAL/PLUMBING
ARCHITECTS DECLARATION
I understand my plans a hall be used on public records CONTRACTOR: JUST CONSTRUCTION
u Licensed Pmfendonal
50 OWN2M BUILDER OE CLARATION
0 f 1 mora.afn.(Su a n 12M eacmp,from 0e Camas Co :My C Law far the
OO followingmason. (anion 7031.5,Business p .,deruos Code:Any city ala County
$ which roqulms a perms re conawe,alter,Improve,demolish,ora sirmy atrocmro
pdorw its Woman,also requires the applicant for O
forsuch permitlc atigncd NmmlCod Valuation
< W,berlice withSeww,utbepmvinamofdmin,Ban nasandsnsclswlsCook)9 Sq.Ft.Floor Area
FCS
(commencingisxemt Sceionm and Th basis far
deNeeged cnandat.Mymnslatde)of
3 9 that io r 31.5 b Ibemfmm and the bur it the alleged osempnt to Any it Penalty
of
not m m:e five nay applicant ss fears B objects the.ppl applicant m. l penntr ala APN Number Occupancy Type
❑I.as owner oftW property,Or my employees with wagon M their sale compereadon,
willdo the won and thesuucrote r not Intended maffased hustle(Sec.7061.BusitaessRe uired Ins ections
aaions
and ProreCode:The re
Concmrs License Isw docs rot apply m an mwmr ofFIFULCU
q P
property who builds or improves daemon,and who Ones such work himself ar through his
awn employers.Provided that such improvements art not Intended or offered for sale.if.
however,the building or improvement is mid within am:year of Completion,the owner-
builder will have the human of proving that he did not Wild.r improve for purpose of S v�q
sale) f J 2005
0 1.as awnar of dm property,am inclusively eomrmtlng with licensed wmrecmts an
cone La des mH (Sec.7014,Busiweer of and rty who ns Code:)Thews Womis Cad ®u I
conselawtlprjoapplyt(Sec un 70 .wnerorpaopertYwW Wildeorlmprow theetan,antl, ®U
Ll-
who contracts forsuch projects with a canuacmrt0 licensed personal w the Com exam's
Lkevelaw.
Cl lamexemptunder Sec ,B&PCfmthlsmnon
Owner Dam
WORKER'S COMPENSATION DECLARATION
1 hereby afnrtn under penalty of perjury on,of the following tlenvations:
I .have and will maintain a Cenincem.roonsen,m seir-am.for Worker's Compen.
.than.as provided for by Section 3700 of Nbo
e lar Code,fe,the performance of of the
work for which this permit is intend.
❑I have and will maintain Women's Compensation Insurance,a required by Section
3700 of the labor Coda,for the performance or the wort far which thin permit In issued.
My Workerc's Compensation Insurance Cartier and Policy number am:
Cartier.-5. � �f> Policy No,�
CECERTIFl�LAIE�EMPTIONFAOMWORK S'
COMPENSATION INSURANCE
(Tbr seNm road Out W completed IftW permit Is fmonc hundred dollars(SIM)
Car leu)
1 certify that In the performance of the work for which this panni,is issued,)shall not
employ any person in my mannerm u In become subject to the Workers'CompensAOon
laws of California.Data
Applicant
NOTICE TO APPLICANT.If.a0cr making this Cenirteate of Exemption,you should
become subject m the Worker's Compensation provisions olden Labor Cade.you must
.,0 forthwith comply with such provisions or this permit shall be deemed mvaked.
,Z,y rA CONSTRUCTION LENDING AGENCY
[-t I hereby arum that them Its conumcion lending agency for the Performance of
W'7 the work for which this permit Is issued(Sec.3097,Civ.C.)
<1J Lendet's Name
L xe dxh Address
V Q 1 certify Nat I have mad this application and rote that thc abuve information In
W!! correct.1 agree w comply with ata city and county oadinsncea and awe laws misting to
0 rV' Wilding construction.and Wmby authorm,representatives of ser city m enter upon the
W above-mentionW property for lnspecdon purposes
(We)Agan to save.indemnify and keep hmmleso the City of Cupcnino against
y7 lianildei,judgments,taus and expenses which may in any way msmc against said City
U a� in consequence of the Standing of 114171scruil.
APPLICANT UNDERSTAND A D WIJC]tp)YPLY ALL NON POINT Issued by: Date
SOURCE REGULATIONS. � ///_JA/Rj1/
SignatumaAppll Canuac,or 127 Date Re-roofs
r
HAZARDOUS MATERIALS DISCLOSURE Type of Roof
WIII the applicant or future building occupant atom or handle hvndow material
an de0ned by the Cupertino Municipal Cade.Chapter 9.13.and the Health and Safety
Cade.Seed..25532(a)7 All roofs shall be inspected prior to any roofing material being installed.
❑Yes ONa
Will the applicant or Futuro building Occupant as equipment ala devices which
If a roof is installed without first obtaining an inspection,I agree to remove
It hustdnon air conuminanu u dclincd by the Bay Area Air Quality Management all new materials for inspection.
imrn:0
❑Yea �No
1 heves rand the hanadlma mamrialsroquitemenu under CNN xr6.95 of thc ralifor
nr Heal sit SaWyCoic&.do.25505,25533 and!M531.1underewldIhatifthe Wilding
Jeer no,currtndY M ani th it y responsibility m nosily the Occupant of the
requimmcnu which beme t race of enirw.te araooynoy. Signature of Applicant Date
OwncrodiltahM.la
All roof coverings to be Class"B"or better