04020017 CITY OF CUPERTINO
BUILDING DIVISION PERMIT �Q T1tACTOR INFORMATION `"z
hvmw..,�rimAS.
BUILDING ADDRESS: SYL-MAR CONSTRUCTION PERMITNO.04020017
.R'S NAME: PERMIT ISSURDATE
r EQUITY
NE: SANITARYN . 1290MOL NO.
ARCHITEC(ENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
'dz LICENSED CONTRACTOR'S DECLARATION Job Description
I hemb afllrm that 1 am lirosaxd under p viilom of Chapter 9(commencing
Z with Sccmm nor Divixlon3of NC Businex�rofeuiuns COUtndetylleenseis �'�j ��1 �®
<< in full f, rad effect ,Y `
�z rt_ sea. DEMO (15000 s4. FT. ) MAR 1 0 2004
— Dau Can
3 ARCHITECTS OEC
4 underuafid my plana shell heated u pas a menrN
_� LienrundPmfess,n.1 BUILDING
OWNER-BUILDER DECLARATION
m
I hereby 41TI Nu 1 am exempt from the Contractor's License Law for the
C G O following mason.E efi n 7131.5,Butimas and P efeaaluni Code:Any city or e.Ynly
$ which mquima a Permit to enneuuet,slur,improv,demolish,or repair ray structure
prior m its issuance,alm rrquirm the applicant for such Permit to Ne a signed statement
thu be is licensed pursuant to the provisions of dim Commutes Llemse Law(Chapter 9 Sq.Ft.Floor Area Value ion .
$ (commencing with Section 7")nf Division 3.1'the folios and Professions Code)or
l� that he u e¢mpt therefrom and the bash for the alleged exemption.Any vlolNon of
nodi mon 7031.5 by om than By any
vdredldo dollars(MOO).Il mbjuu the eppliunUo a civil penalty of 3 MT1 MMW 0 0 Occupancy Type
❑I.uawncr of thepropcny,or my empl,you with weguuthelr sole compenull,n,
will do thework.and the The
License, awdo(,reale(pea]801,Bwlmss
and Professionswho
Code:mpr Canuar ars License,low dam rot apply lf an owner is Required Inspections
man
property who braIIds or improves improvements
and who doessuch work himselfor edthrough his
own employe".
however.
the uiprovided that improvements lie not Intended m offered for Owner.
Wilderr.Ne building or Improvement is mid within one year or commcompletion.for purpose
owner
Wilder will leave the buNen of proving But he did rot Wild or Improv for puryom of
rale.).
1,as owner of the propeny,am exclusively contracting with licensed contractors to
ronetmm Ne project(Sec.7004,Business and Profusions Cade:)The Conlsacwrh Li. '
came Law docs not apply in an owner or pmpeny who builds or improve Neuron.rad
who contacts for such projects with amnuumr(s)licensed pursuant an the Conuocmh
License Law.
❑I am exempt under Sec. _ .B B P C for this mason
Data
WORKER'S COMPENSATION DECLARATION
1 hereby Orion under penalty of perjury am of the fallowing declarations:
1 have and will mdntsin a Carl of Consent to self-imam for Workers Compen-
sation,u provided for by Section 3788 of Jur Labor Cade.for due Performance of the
work for which this permit is issued.
(]1 have and will maintain Worker's Compensation Insurance,as required by Section
3708 or the Labor Code,fm the perform.of the work For which this permit is iumd,
My Work es Compensation Insurance carrier and Policy number art:
Canter. �'E I OF Pollry f9pr� .
CE IFlCATE OF E%EMPITON R RS'
COMPENSATION INS ANC,
(This motion recd not Wcomplemd if the permit is fortune hundred dollars($100)
or less.)
1 unify the in the performance of the work for which this permit is issued.l Nall not
employ any permit in any mmurm at w become subjeet in the Workers'Campematiun
Laws of California.Data
Applicant
NOTICE TO APPLICANT:If.after making this Cenilicate or Exemption,you should
became subject or the Workers Compewtion previsions of use,Labor Cade,you most
Z forthwith comply with such provision or thie Permit snail bo deemed revered.
zO CONSTRUCTION LENDING AGENCY
(•+rA I thereby afr m that Nem is a eoommeth n lending egcncy for the perfurmanm of -
Qi > the work for which this permit b issued(Sm.3M.CN,C.)
ALender's Name
=z Lender's Address
U Q 1 anify that I Mrs mad this application and sou that thc shove information is
LT. F correct.I agree w comply with all city and county osdureacea and sum laws rehling to
DU building construction,and hereby auNorim representatives or this city to enter upon the
W movomentioned property for inspection purpmea
14 (We)agree in save,indemnify and keep harmless the City or Cupertino against
h Inhilitice,judgments,emu and expcssu which may In my my amroe agaiut said City
V 7 in consequence of the graining of this Permit.
r1• APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON.P INT Issued by: Date
SOUR REGULATI NS.
6lgorfitM1 —SYl.�►1A2t Re-roofs
sof Applican ortmetto�C r be
HAZARDOUS MATERIALS DISCLOSURE Type of Roof
Will the applicant or future building occupanumm or handle huardous meurial
u dcfimd by tint Cupertino Mu 'eipal Code.Chapter 9.12.and tie Health and Safety
e,Bacton zss3z(a)7
E)Yes No All roofs shall be inspected prior to any roofing material being installed.
Will the applicant or fnum '(ding occupant um equipment or&,I.which If a roof is installed without first obtaining an inspection,I agree to remove
Il huvdnm air mntsminume Toed by the Bay Ares Air Quality Management all new materials for inspection.
iurict7
❑Yes o
I have mol the hvasdmu maurialarcquiremcnu under Chapmr 6.95af the Glifor
ria Hc.t"Safcty Cada Secd=m M5,35533ad25530.lunWmandthwifNc Wilding
docs ml currcmly haw a wnant,Nat it is my rcapomihilily w nnJly du occupant of the
reqsmentswbia aetbc etpri,rwissa ceaceni
r r ,r ,p y Signature of Applicant Date
o authorivsdagcnt 'D All roof coverings to be Class "B"or better