05070113 CITY OF CUPERTINO 77747777777777^ •'� '
B(ili.DlNc Divlslon ' PERMIT �sCONTRAC QR INF�ORMATTUN
BUILDING ADDRESS; EVERGREEN DC CO (LHC) PERMIT NO.05070113
NER'S NAME:. PERMIT ISSUE DATE
-TSENG-.0 E
NE: - SANITARY NO. CONTROL NO.
(408) 887-0186
ARCHITECT/ENGINEER:` BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
306 I LICENSED CONTRACTOR'S DECLARATIONIdi IOb Description
r I hereby affirm that 1 am licensed under provisions of Chapter 9(commencing P
with Section 7000)of Division 7 of the Business and Professions Code.and my license is
mmumrteandercm I HOUSE DEMO-DOUBLE FEES TAKEN DOWN
j 2 Lkedm Class Li.0
t' Date _ ' ARcxl7ECanoFcuRAT10N WINO PERMIT-REPLACES ORIG' 04120158 4
1 understand my plans shall M used As public memos i
JyU , I a
Licensed Professional F�AiB LE®
gy 3 Oat I AM CMPI from
mDECLARATION �,YYV/AA�`
i<f Phmaso .(Item that 11. exempt from i r Connector's o :License Low for the 0
0 0 following moron.(Section 7 o s Business and ne,Chalons Cade:Any city or county.
$�
which rtyulrts a pemrit In cnmtruc4 alien Improve,demaltsh,nr mpolr any structure
zs^ poor M its luuatme,also Mquire, the applieanl for.uchre6n lllo Bleasigmdmtcmcnl
< Ihat he i.immeAd in, sotto thup mvknions of the Contractor's License Law(Chapter 9 Sq.Ft.Floor AreaTA42ftluatoo 0 0 0
(commencing with Section 7000)of Division 3 of tho Businevand Professions Cade)or.
thithe is ass t tiieMr.I and Ihe,Euis tar the alleged exemption.Any violation ofone 9ft
Semon 7051.5 by any applleant farapermtuubjects the applicant to a civil penally of t APN Number c Type
not more an It bond Collis($SW):, "
! I 35916013 . 00
will do work. Ad property, rmyemntendes with wells,forum(anl compensation,
anddathewerk.ande:TbeCreucteumm�anseaw do forum not apply4.toComity ss
of Required Inspections
'
and property
wh bu Code:
The Canmemr's Lisi:nse Law dace not apply ll,t owner is q P
Own erty wyees,provided
that
thrmprove wh�deeuuc tendo himseeed for
ugb his ,
own employees,-provided that vem improvements art not e intended C M round for We.if.
howWilde, the building or Improvement is hold did
one Xu of mpro a mn.for the rise of
bulkier will have the burden of proving out he did not Mild or ImProw for purpose of
uteJ.
OM I.as owner of the property,am exclusively contracting with licensed contractors he
construct de project(Sec.70W,Business and Professions Code:)The Contractors U. t
amen law don not apply to an owner of property who W LIN or bnprowh thereon,and,
who Contracts for such projects with a contrular(O licensed pursuant w thA Contractors
License Law. '
0 am a&P_Q far this rwam - r
er- Date —Z- O� ._ _. '.+ _ -
11,A
WORKERVICtiMPRIESATION DECLARATIONIF
thereby drum under penalty of perjuryoncof the following decluations:
❑1 haw and will maintain a C,rOfeate.fCWs mI to self.mune fon WorkersCompen-
ration.M provided for by Section 3700 of we Labor Code,for the performance of the _ ..
work for which this permit is issued.
❑1 have and will maintain Workers Compensation Insurance,as mquired by Section _
7700 of the labor Code,for the moarm rm.of the.,it for which this permit is issued.
My Workers Compensation Insurance carrier and Policy number All
caller. Policy No.:
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(O sstcuw need nothecompleted ifthe permit Is forone hundred dollars($100)
or Ise.)
I certify that in the performance of the work for which this permit i inucd,'I shall not
employ any person In any manner An At in become subject ld the Workerf Compensation
Laws of Cali(��R�'DJte
APPlichm
NOTICE TO APPLICANT:If,a ma ing this CcniOuu of Eumption.you should
become subject to the Worker's Compcnation provisions or the labor Cade,you mus
.,0 roMwith comply with such provision or this permit be deemed nvokcd.
Zn CONSTRUCTION LENDING AGENCY
[ti l hereby alRrm that then h a conswcunn lending agency for the Performance of
fY.7 the work for which this permit is issued(Sec.70977,Civ.C.) '
QLanders Name
D Z finders Add.
V Q 1 artily that I haw read Nu aPpicad.and.tats Nu the.bow Information Is .
ly ^ Correct.i agrs to comply with all city and county ordinhnns and sum laws misting W
O SV' Wilding construction.and Mmby auNmien representatives of this city w Amur upon the
W aWw-menuorted property for inspection purposes.
gL (We)agrte to an.Indemnify and keep harmless the City of Cupertino against
IA Imbilitiu,judgments.cants and expenses which may in my way acetic against aid City
V Z in consequence of the Swung of thus Permit.
APPLICMT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT Issued by:9 Date
SOUR OULATIONS.
7 Re-roofs
Signature ofApplican Aunctor Date
HAZARDOUS MATERIALS DISCLOSURE Type of Roof
Wit the applicant W future building Occupant son or handle huudous material
M defined by the Cupertino Municipal Codc,Chapter 9.12,and The Health and Safety
ode,Section 2553x(.)7 All roofs shall be inspected prior to any roofing material being installed.
❑Yea I )§No
Will the applicant or rulam building Occupant use equipment or devices which If a roof is installed without first obtaining an inspection,I agree to remove
AMR hesardom it contaminants as doomed by the Bay Area Air Quality Management all new materials for inspection.
District?
❑Yes_ <No
I have mad the Invention.materiels requirements under Chapter 6.95 of the Castor. – -
nitHeal"Safer Cal.Sec6ms25505,25333and25534.Iundenundthulfthe Wilding
don not rel y a A IMAM,that It ts my reepomthility to notify the oecupmt of the
req ire emu whi ustM metpdarml or A CArtineam of Occupancy. Signature of Applicant Date
All roof coverings to be Class"B"or better
Own u inah.nved.getn Dow