04030025 CITY OF CUPERTINO
CONTRA bI2,INUM�1OL�1,a
BUILDING DIVISION PERMIT k „
BUILDING ADDRESS: PERMIT NO04030025
o 4 O 3 O O 2 S
'Luc
NAME: PERMIT ISSUE DAM
VOL
ONE: SANITARY ND. COM80L NO.
ARCHITECT/ENGINEER: BUILDING PERMITINFO
BLDG ELECT PLUMB MECH
B o o LICENSED CONTRACTOR'S p DECLARATION
I ion 1 affirm that I em of
under provision of Chapter 9(commencingbeemsis Job Description
with Section 7IXg3)of Division 3 of the Business and Profeuinm Code,and my licen,e Is
in fullfo eandercml,6 �eS' CC�/l7 TENANT IMPROVEMENT
Zm License COcntru /� N
y ARCHITECTED ATION CONTRACTOR: TICO CONSTRUCTION 'N��.
Iundersland my plans shall be used as public m000ds SUBCON. INDOOR (HVAC)
�s`D
MAR 2 2 2004
30t; Licensed Professional
5 OWNER-BUILDER DECLARATION
oO I hereby alarm that 1 1. exempt from me Contractor's o License taw for the
ioO following men a.(Scctiun 703 construct,
Baiter, and improve.
de run Code:Any city or county BUI�DIgkat
+�$m which its issuance.
s u a permit m rimaM alter,improve,demolish.ri repair any awcmm I V '+
Fly that heor itscensed p,alanntto Me Meapplicantof forsme Connector's
oerror'so rile Licea Law(ed atstemenl
a Ibuheincing edpumuaotlothepmvialoesaftheCo usinsw Liccoxa3mrC ode) 9 Sq.Ft.Floor Area Valuation
(c:t he is exempth Sectionan and o[Division 3 of the aged exempt Professions Code)of
.. met W is sump(utcmfrom end me basis for 0n,alleged exemption.My violation of 819560
Section 701.5 by any applicant for a perell subjects the applicant o a civil penally of APN Number Occupancy Type
nut mom than five hundred dollars($500). P y yP
❑I,as owner ofthe property.m my cnployees with wages as their Men compensation,
w i II do dm work end me swan m is am intended or offered fm sale(Son.7044,Bninua
and Protectionist Code The Conmcroh License law does non apply W an Owner of Required Inspections
propertywho Wildsorimpfaves lhermn,endwha doessuch work himulfor through his
awn employ..provided mm such improvements sen natlnmnded oreffered for sale.If.
however,the building or improvement is sold within one year of compledon,me owner.
builder will have the burden of proving that he did Int Wild Or Improve for purpose of
sale.).
❑1,as Owner of me property,am exclusively connecting with licensed contractors to
construct the project(Sec.7044,Business and Profession,Code:)The Connector's Li.
cense law does not apply to an owner of prepeny who Wilds or impmwa Ihemen,and
who contracts for such projects with a contractor(s)Banned pursuant to me Contractors
License Law,
0 I son exempt under Sm. .B B P C for this mason "
er
Data
WORKER'S COMPENSATION DECLARATION
1 hereby affirm under penmty,of perjury one of the fallowing decluntions:
1w-k
have and will maintain a Con ficamaf Consent mulbinsure fm Worker.Compel-
n,u provided for by Section 37M of me labor Cotle,for ON performance of me
for which this Permit is issued.
have and will maintain Workers Compensation In,urance,n required by Section
Mme Later Code.fm the perfrmsnm crude work for which this permit Is issued.
orkcr'f ConsatlonInaunnmcalrfcrend Poli n sho�EI`hl� Policv CERTIFICATE OFEKEMPfIO' 044 WORKERS'
COMPENSATION INSURANCE
(Thissectlon need not temmpleted Bthe permit is foronc hundred dollen($100)
err lna.)
I mnify that In the performance of me work for which this permit is issued,I shall not
employ any person in any manner an a to become subject to ftworticenr Compensation
Laws of California.Dam
Applicant
NOTICE TO APPLICANT:IL afar making this Certificate of Exemption,you should
become subject to the Worker's Compensation previsions or me tabor Cade,you met
Z rOMwith cn o,ty with such pmvidum or this x moh.hell W deemed revoked.
Z O CONSTRUCTION LENDING AGENCY
[r Ihereby affirm that there isa commuctinn lending agency for the performocc of
Fri> the work far which thin permit is issued(Sec.3097,Co,C.)
6Wi A Lenders Name
z Lender's Address
Q0 1 certify that I have mad this application and sue that the above information is
U.Fcorrect.l agree to comply with all city and county ordinances and state laws mixing to
building construction,and hereby mutation representatives of this city to enter upon the
` a ahow"mentioned prolixity for inspection purposes. .—
!f"t (We)agree m save,indemnify and keep Nomura sera tW City of Cupertino againt , y
res Iiebilitiu.judgmcnts, and cxpen,cs which yin any way eccme against said City `'j L/T
(„)z in consequence of c gr ling of min perm /
APPLICANT DER ND N ILL OMPLY WITH ALL NON-POINT Issued by: Date
SOURCER U
ruL
Re-roofs
at ApplicanVCOnRDO Dete
HAZARDO SMA RIALS (Mom orsu Type of Roof
WillmteCupenlor fmu building Occupant Chapter
morcor handle hmalth andndous aterim
as defined by Um Cupertino Mon ipel Code.Chepmr 9.13.and tW Health and Safety
de,Scotian 2553$a)1 All roofs shall be inspected prior to any roofing material being installed.
❑Ye9 V
FWill the applicant err fmu building occupant use equipment or devices which If a roof is installed without first obtaining an inspection,I agree to remove
it havardaas air canmminan dctincd by me Bay Area Air Quality Management all new materials for inspection.
District?
❑Yes
1 have mad me moardms materials requimments under Chapter 6.95 orM a Califon
me Halm&Sunny Codc,S cams 35505,25533 and 25534.I understand Met risen Wilding
does not currently h nam met it is .punsibility m notify me Occupant of me
myuimmeno w 'Mu W etP r u ee or.Cmtinctear OceaPosey. Signature of Applicant Date
Narixm agent ,� All roof coverings to be Class "B"or better