04080213 (2) CITY OF CUPERTINO
BUILDING DIVISION PERMIT �GONTRAC�"TO�R IlVFORMATION
BUILDINGADDRESS: ROCKWOOD CONSTRUCTION C0RPPERMEENQb4080213
in-Au PONNY DR
OWNER'S NAME: PERMIT ISSUE DATE
WAY, STE 5 ITARY O OL NO.
NE:
BUILDING PERMIT INFO
ARCHITECT/ENGINEER: BLDG ELECT PLUMB Met
Q 0
UOp LICENSED CONTRACTOR'S DECLARATION
U I "by
affirm Upas I.laermed under pmoisimm of Chapter 9(mmmencog Job Description
wish Sce n7 infDivision3ofthe Busineuaod ProfcssiomCode.andmyliccnuis
Z ¢Tres oder,«t. REVISION--IN HOUSE USE ONLY
License Class�Cl NL
�c Date cant,«tar AMNO NEW PERMIT ISSUED/ ORIG. #04060046
AR afTECTSDECLARA ,f
�i S 1 un stand my plans II W use 6 blic¢cords
As
D As
''teak Liccnu YnTC3giBiRi
5 ' OWNER-BUILDER DE Ce �ATIII /
iY 1 hereby affirm that 1 em exempt from the Contractors License Law for de
F.p O following mason.(Section 7031.5.Business and Professions Code:Any city arcounly
which requires a permit m ennsuucl,alter,impmee,demolish,or repair any structure
FZipoor to its issuance,also mquucs the applicant for such Permit to file asigmd statement
that the is licensed pursuant to the previsions of the Commewrs License Law(Chapter 9 Sq. Ft. Floor Area Valuation $0
'Is-$ (commencing with Section 7000)of Division 3 of the Business and Professions Cottle)or
- that he u exempt therefrom and the basis for the alleged exemption.Any violation of
Section 7031.5 by any applium far a permit subjects the appBeam to a civil penalty of APN Number Occupancy Type
nal mom Nan five hundred dollars(5500).
1,as owner of the prruy,or my employees with wages as their sole compensation, 35901305 00
will do the work.and dteawemre is not intewed or offered for ago(SO,.71y44,Bumoss Required Ins actions
and Professions Cade:The Co muctor'i License Law does not apply m e an Owner or q P
proper y who buil&.6rePr ares Nercon,and whodoessuh work himself c r through his
own employees,provided that such improvements an,not intended or offered formic.if,
howeve,,the building or improvement is sold within one year of completion.are owner-
builder will have the burden of proving that he did not build or improve for purpssse of
sale.).
❑1,as owner,of the property,am exclusively eomncting with licensed anuaclom m
construct the project(Sec.701.Business and PrDOAROM Crile:)The Contractor's W. .
anti Law docs not apply to an owner of property who Wilda Or improv thereon,and
who contracts for such projects with a conuactor(s)licensed pursuant no the Convenor's
License law.
1 am exempt under See .Bk PCfarthis reason
OW �2 Date LZII-0
'XURKERS COMPENSATION DECLARATION
jo1 hereby aliren under penalty of perjury ane of the following declarations:
have and will maintain a Cenificam of Consent m self-insure for Workcr'sCompen-
smion,as provided for by Section 37M of the labor Code.for the Performance of the
work for which this permit is issued.
❑1 have and will maintain Worker's Compensation Insurance,as visioned by Section
3700 of the labor Code.for the performance of the work Int which this permit is issued.
My Wmkcr's ComPonauon Inauremes,canner and Policy numbs,are:
Cartier: Policy No.:
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(this section recuse,Wioarnplcugl itlhfcrtn' isrmo hundred Mllan(SIIX)
or less.)
1 ccnify that in the performance of the work for which ,mitis issued,l shall not
employ any person in my manner bWco cyl Ad loo IMWodC�mpewuon
L of California.Date 8a-
.CE TO APPLICA :If,after making this Certificate of a Imtnyet tmlii
ante subject a the WorrcrS Compensation previsions of the Lenin Code,you most
.JO forthwith comply with such provisions at this Permit shall W deemed revoked.
Z r~7. CONSTRUCTION LENDING AGENCY
P1 hereby affirm that there is a constmctino lending age«y for the performance of
a5., Tho work fur which this permit Is issued(Sec.3097.Civ.C.)
IL7 Lender's Nam
c
G Lender's Address
Z
U C 1 certify that 1 have read this appliestion and sate that Upe above information is
fk. PCorrect.1 agree to comply with ail city and county ordinances and state laws relating to
pU building construction.and hereby authome mpmsenutirrs of this city to enter upon the
} fbl above-mentioned property far inspection puryoses.
(We)agree no save,indemnify and keep harmless the City of Cupertino against
F h liabilities,judgments.costs and cape^•".which may in any way acerae against said City .
U in consequence of the granting of this permit.
^ APPL ANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT Issued by: Date
SO CE REGULATIO S.
24F. ` Re-roofs
Signature of Applicant,Contnemr Date
HAZARDOUS MATERIALS DISCLOSURE Type of Roof
Will the applicant or future building Occupant store or handle h omNous material
as dcMed by the Cupertino Municipal Code,Chapter 9.11,and the Health and Safety
Code,s«son 25532(a)? All roofs shall be inspected prior to an roofing material being❑sec, ONO P P Y g g installed.
Will the applicant or(tire¢building o«upam esu equipment or devices whicM1 If a roof is installed without first obtaining an inspection,I agree to remove
ha srdnua air cantamirants as cfiud by Ups Bay Arta Air Quality Management all new materials for inspection.
nice
❑Yes Nu
1have read the hvaNnus materials requiem nerunderChaper6.95oftheCahrn,-
riaHeol"Safcty Cale.Secumu25505.25533 and 25531.I undersuM lout lithe Wilding
dam no cuncmly. w e tenant Net it is my responsinility m notify the Occupant of Nc
myon c w mug Is,ren poor wissuarra ofQ91ficga of Occas Signature of Applicant Date
Owner :bulnorncd aFe^t Date All roof coverings to be Class "B"or better