04020155 CITY OF CUPERTINO ,CON "� �°�*" :
BUILDING DIVISION PERMIT RA T�OR,I1'� URMA.TI01�1
BUIL DING ADDRESS: PERMITNO.
04020155
OWNER'S NAME: PERMIT ISSUE DATE
NE: SANITARY It� 4:7@MtOLNO.
ARCHITECT/ENGINEER: BUILDING PERMIT INFO
- BLDG ELECTe PLUMB MECN
0 0 0
=00 LICENSED CONTRACTOR'S DECLARATION - - - Job Description
1 hereby affirm That 1 am licensed under provisions of Chapter 9(commencing
n wid,&.,Ian7W11)af Division 3oflhe Busineuend Profesana Code,and my license is
Zt I.full force rand cffett
5p LicenseClaca Liux REMODEL--CONVERT LAUNDRY RM TO 1/2 BATHRM
z Dam Contractor MOVE THE WINDOW-FORMERLY UNIT B
Oj ARCHITF-CPS DECLARATION
I-li2 I understand my plans shall he used ss public records
�yU
G
Licensed Professional
OWNEus corm litfrom
m The RATION
I hereby affirm that 11. excmnT from Ne Currencies'sCOC License Law far The
9 following mason.(Section]1131.5,Business and improve,
de arta Cade:Any city 3 county
which rtquiras a Permit us Construct,due plies improv,h Permit t or mash any ned tatemute
pdofmits censed c,tawntin the dueapplicantConleater's eon.le a aw(Chmmcnt
£ C
that hemaing with
itpSectio7000)of DMoms 3theic Buacmr'a Licenseisw(C Code)or Sq.FI.FIOOI Area Valuat p000
y+ $ (eammcs exemttSerafrnssundtfDivisi for
ofthc Business and Profcnvi Cndc)or b
Nn he is 31.5 b sanmfram and or balm for the cis The exemption.Any Walation of
Section 71131:5 by any applicant for a petrels subjects the application o ad vil penally of APN N tuber Occupancy Type
not mote Than five hundred dollars(M). a�r 'aex;s.,, 4
❑1.a owner of the property,or my employees with wages as Their soleeampenamlon. 51l,, .O.' ' 35,. %
will do she work and the suacsum is not intended orotreted paraale(SOM,711$6,Bushtess Ig
and Professions Code:The Conuaclor'a License Isw docs not apply m an owner of 'Required Inspections
property who buildsorimpmmtkmmon,and who daessuchwarkhimselfor through his (} A,/
own employees,provided thatsuch improvements arc notinanded Castrated totaal&If. DCC 1 CYC• 2004
however,Ne building or improvement is sold within one year of completion.The owner.
builder will have The burden of proving That M did not build or improve for purpose of
ple0. ��
Rl 1,as owner of The property,am exclusively contracting with licensed Conuumrs to
Cau se La the project(Sec.Todd,Business and property
wssimts Codei The Conuereon.saidLi-
Cause Li
who contracts
Law doer not m ts owner of property who builds rs improves thereon.and BUI111111 Y�
whonse acta(or such projects with acontrecmr(s)licensed pumuansm the Conuacmh
License Law.
❑lam a�em,/ps�Color S.C. B&PCI rIh' ruacn -
wui/ o`-W Dem
`�-Pv—W CER' COM f i RATION
I hereby affirm under penalty of perjury one of The following declarations:
❑I have and will munlun aCcAocsteof Consent to self-insure fwWorMri Compcn.
melon,as provided far by Section 3709 of the Inbar Cade.(w the performance of Ne
work for which this permit is issued.
❑I haw and will munsun Workers Compensation Insutmce,as mquimd by Section
37W of an,Lebo,Code,for the petfmmmce of The work far which this permit I,issued.
My Workers Compensation Insurance carrier and Policy number am:
Cartier: Policy No.:
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(This section need nwhceomple ed Tithe petmitIs ounce hundred dollars($1 00)
or Mss.)
I certify That in Ne perfmmanTce of she work for which this permit is issued.I shall not
employ any person in my manner an To To become subject To Om Workeri Compensulon _
Laws of California.Dam
Application
NOTICE TO APPLICANT:IL after making this Cemificam of Exemption;you should
become subject in the Worker's Compensation provisions of the Labor Code,you must
Z forthwith comply with such provisions Cr This permit shall be deemed rtmkcd.
.zi O CONSTRUCTION LENDING AGENCY
[-. I hereby atrrrm that There is a construction lending agency for tits perfurmmce of
fl 7 the.,it far which this permit is issued(Sec.3097,Civ,C.)
W�Q Lendcfs Name
.7 z I<nder's Address
U 0 1 certify that I have dead This application and scam that the above information is
U. couttt 1 agree to comply with all city and county onfina ma and stale laws relating m
0U building construction,and hereby audrodn mpmaentstiws of This city to ansa upon the
W above-mentioned propel for inspection purpCaca
(We-)agree To rive,indemnify and keep harmless the City of Cupertim.&¢Inst
C1, liabilities.judgments,costs and expenses which may In my way same against aid City
in
V APPLICANT eUNDERSTANDS ANDof The granfing;of WILLWILL COMPLY WITH ALL NON-POINT Issued by: Date
SOURCE REGULATIO S.
�au0 Re-roofs
Signal of ApplicmT/Conannum Dam
HAZARDOUS MATERIALS SCLOEURE Type of Roof
ill the applicant or future building Occupant stem w handle husmmus mounted
as I recd by The Cupertino Municipal Code,Chapter 9.13,and she Hcalm and Safety
Code,Section 35533(87 All roofs shall be inspected prior to any roofing material being installed.
❑Yrs AN.
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
emiI hazardous air contaminants as defined by tits Bay Atea Air Quality Management all new materials for inspection.
Duldict7 ✓✓✓
❑Yes yNu
I have read the hma ileus mauriels,equimmmes under Chapmr 6.95 of the Califor.
nia Hcabli SaloyCei Swtions 25505,25533 and 35534.1 understand thatif The Wilding
does not currently how a unanl that it is my responsibility m notify The occupant of the
man, ttheriormissumcc o
duci pf a Cenifcale of Oce y. Signature ofApplicant Date
wz; �" '��� g All roof coverings to be Class"B"or better
OVner or authorized agent Due