04050005 CITY OF CUPERTINO a^�Oi�°g}��.�. s.
BUILDING DIVISION PERMIT xWIUCTO R"' j^M'O"- ,
BUIL DING ADDRESS: 1ERMITN904050005
ERS NAME: PERMIT MUE DATE
IJ
NE: SANITARY N0. CONTROL N0.
ARCHITEC(ENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
0 0 0 0
A o o LICENSED CONTRACTOR'S DECLARATION-
�r F I hereby affirm that 1 am licensed under previsions of Chapter 9(commencing lob Description
aSj with Section 7")of Division 3 of Ne Business and Professions Code,and my license is
off infull Ore,cmd ffm 30-DAYS TEMP PERMIT (UNTIL 06/03/04)
5 Z License Class Us.N
,Z, Dam C.ntractor ORIG. #04030226
ARCHITECTS DECLARATION
1 understood my plans shall W used as public neords
Dau
;oC Licensed Professional
S OWNER-BUILDER DECLARATION
i1 hereby mTires that 1 am exempt from the Contractor's License Law for the
D O following moron.(Section 7031.5.Business and Proesestona Code:Any city or county
which requires a Permit to consuuc,,altar,improve,demolish,or repair any structure
os prior to its issuance.else requires the applicant for such Permit to file a signed statement
FZi that he is licensed pursuant o the provisions of mLi
e Contractor's cese nLaw(Chapter 9 Sq.Ft.Floor Area Valuation$49
a�m (commencing wide Section 7000)of Division 3 of On Business and ProfcasionsCode)or 'J
$ that he is exempt durefrom and the basis for the staged exemption.Any sidled on of
Schon 7031.5 by any applicant far a Permit subjects the applicant to a civil Penalty of APN Number Occupancy Type
not mom Wan five hundred dollars(5500).
❑L as owner of the pmp tly,or my employees with wage,as their sal.compensation. 35717012 . 00
will do the work,and We swnu a is nut intended or offered fo...1.(See.70x4,Business
and Pmfeuiou Code:The Contectort Lianas Law does not apply M an owner of Required Inspections
property who builds w improves thereon,a nd who doe,such work himsel f or though his
own employees,provided that such Improvements an not intended proffered for sale.If,
however,the building or improvement is sold within one you of completion,me owner- (�
builder will nave We burden of proving that W did not Wild or improve for purpose of
VmJ. X
❑1,as owner of me property.am exclusively contracting with licensed contractors in pj
construct the es project(Sec.n an wner oas and Professions Code:)7M Conhutor's d _
came IoW Baer not apply a an owner of property who Wilds M improves NORMS.and
who se Law for such projects with aconwetoKU IlcanuO punuam to the Cenvaaots
License Law.
❑1 are exempt un ,R&PIC f�ar Ithismes�on
er
Data -�l7NVU'
ENSATION OECLARTION ata
hereby affirm sande nett of perjury one of du follox'M¢elaelffltloas:
that and will main Wn a Ceruficem of Careen,to self-imurt forworkcrYCompen-
.it.,as provided far by Section 3700 of the labor Code,for the part....of the
work for which this permit is iuucd.
❑1 nave and will maintain Warker's CampeIt In.Insurance,as required by Section
3700 of the Labor Cade.far me p.Rarmence,(the work forwhich this pemri,is issued.
My Worker's Compensation Insurance carver and Policy number are:
Cartier: Policy No.:
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(ndsmetlon need notnecompleuA if the permit isforone hundred dollus($100)
leu.)
1 canify that in the performance of me work for which this permit is issued.I shell not
employ any person in any manner m as to become subject to the Workoi Compeasadon
Laws of California.Data
Applicant
NOTICE TO APPLICANT.IL after making this Cmificau or Exemption,you should -
become subject to me Workers Compensation previsions of me Labor Code,you must
.70 foMwith comply with such provisions at this Permit shall W deemed revoked.
z r~N. CONSTRUCTION LENDING AGENCY
[--i I hereby affirm that then is a construction lending agency for the Performance of
C> the work for which this panni,i,issued(Sec.3097,Civ.C.1
GQ Lzndee's Name
=z Lender's Address
U I cenify that I haw read ted,application and sum met the be.information is
a.f" conen.l agree to comply with all city and county ordinances and state laws miming to
DU building commotion.and hereby authories representatives of this city to enter upon the
W shove-mentioned Property for irmccuor purposes.
CI. (We)agree to sew.indemnify sed keep harmless the City of Cury nine,against
ti cA liabllitles,judgments,costs and expenses which may in any way memo against mid City
U^ in APPLIT
egeeNeOf LW granting Of UNDERSTANDStpermit.his ANWILL COMPLY WITH ALL ON-POINT Issued by: Date
soU EGULA NS
Re-roofs
Siptuthe of UCon ctor Dam
HAZARDOUS MATERIALS ISCLO U E Type of Roof
Will the applicant or future building occulamnore orb c harmomm...teriil
I WL defined by me Cupertino Municipal Code.Chapter 9.12.and me Health and Safety
e. 0 en zssu(an All roofs shall be inspected prior to an roofing material being❑Yes No P P Y g ginstalled.
Yen
the applicant or rLJh WRWng«caporal am egaipmenl or d.m.e,onto.$ If a roof is installed without first obtaining an inspection,I agree to remove
it hosedous air contaminants as defined by the Bay Area Air Quality Management all new materials for inspection.
District? .
❑Yes _16Nu
1 have real the hxaardous materials nquiremens under Chapur6.95 of the Califor-
niaftaalth&SafetyCode,Sectom25505,25533md25534.lun modthuifine Wilding
docs notppppu ,ly how en4 that it's my reapoasihility m no' du¢upon,of c
mquireg�cn' ach tons mel pdorto' seance ofY Cenifmau r edq 3� Signature of Applicant Date
Owner syr aamariaaa at oma All roof coverings to be Class"B"or better