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090401050 z forthwith comply with such provisions or this permit shall be deemed revo . ZCONSTRUCTION LENDING AGENCY " E -d tier I hereby affirm that there is a construction lending agency for the performance of (� i Ode work for which this permit is issued (Sec. 3097, Civ. C.) W A Lenders Name Lenders Address V C I certify that 1 have read this application and stare that the above information is LL, H cormCL 1 agree to comply with all city and county ordinances and state laws relating w 0 U building construction, and hereby authorize representatives of this city to enter upon the above-mentioned property for inspection purposes. W W (We) agree to save, indemnify and keep harmless the City of Cupertino against F -d liabilities, judgments, toss and expenses which may in any way accrue against said Cil) V Z in consequence of th granting of this permit APPLICANT U &STANDS AND WILL COMPLY WITH ALL NON -POINT SOURCJREONS. Signatureontractor Date ZARDOUS MATERIALS DISCLOSURE t or future building occupant store or handle hazardous materia as defined by the Cupertino Municipal Code. Chapter 9.12, and the Health and Safes; lodc, Section 25532(x)? Yes o Will the applicant or future building occupant use equipment or devices whic emit hazardous air contaminants as defined by the Bay Area Air Quality Managcmcr District? OYes *0 1 have toad the hazardous materials requirements underChapter 6.95 of the Califn nia Health & Safety Code, Sections 25505, 25533 and 25534.1 understand that if Onc buildin does not cturen ly have a tenant at it is my responsibility to notify the occupant of it reyuirementsllplch must t prior to issuance of a Certificate of Occupancy. [/ y. -9z n-. q Owneror aut ri d agent Issued b -i: Re -roofs Type of koof All roofs shall be inspected prior to any roofing If a roof is installed without first obtaining an it all new materials for inspection. Date being installed. I agree to remove Signature of Applicant Date All roof coverings to be Class 'N' or better CITY OF CUYililii`f BUILDING DIVISION PERNIIT� �U� " ' PERMIT NO. BUILDING ADDRESS: 213 8 4 DEXTSTEVENSr�1 7 7! RED KI=PERMIT ISSUE DATE nWNER'S NAME: CONTROL NO. PHON (4 0 8) 2E7-4088 BUILDING PERMrr INFO ARCHITECT/ENGINEER: BLDG ELECT PLUMB MECH Q p C LICENSED CONTRACTOR'S DECLARATION Job Description U I hereby affirm that I am licensed under provisions of Chapter 9 (commencing Z 5 with Section 7000) of Division 3 of Ode Business and Professions Cocde, and my license is RMV / &PLC: / &MDL (2 8 8) KTC HN , BTH NO NEW F I XTRW I TH in full farce and effect 5�7 ©! 5 License Class Contr*actar o EXT�NO RE—RF OR STRCTRL 3 Date RCHTI•ECl'S DECLA ATION I understand my plans shall be used as public records m �yU Orn Licensed Pmfessional OWNER -BUILDER DECLARATION i< x I hereby affirm that 1 am exempt from the Contractors License Law for the p O following reason. (Section 7031.5, Business and Professions Code: Any city or county K m Pi which requires a permit to construct. alter, improve, demolish, or repair any structure v ' y prior to its issuance, also requires the applicant for such permit to rile a signed statement S Ft. Floor Area 9 q Valuation ? < that he is licensed pursuant to the provisions of the Contractors License Law (Chapter Y FT- C (commencing with Section 7000) of Division 3 of the Business and Professions Code) or 12 0 000 5 S that he is exempt therefrom and the basis for the alleged exemption. Any violation of APN Number by applicant for a permit subjects the applicant to a civil penalty of Occupancy Type Section 7031.5 any not more than five hundred dollars WOO. 3264106:3.00 ❑ I, as owner of the property, or my employees with wages as their sole compensation, the structure is not intended or offered for sale (Sec. 7044, Business Required Inspections will do the work and and Professions Code: The Contractors License Law does not apply to an owner of property who builds or improves thereon, and who does such work himself or through his that such improvements are not intended or offered for sale. If, own employees, provided however, the building or improvement is sold within one year of completion, the owner - build or improve for purpose of builder will have the burden of proving that he did not sale.). Q I, as owner of the property. am exclusively contracting with licensed contractors to 7044, Business and Professions Code:) The Contractors Li- construct the project (Sec. cense Law does not apply to an owner of property who builds or improves thereon, and . who contracts for such projects with a contractor(s) licensed pursuant to the Contractors License Law. I am exempt under Sec. B & P C for this reason 'wner Date WORKER'S COMPENSATION DECLARATION I hereby affimr under penalty of perjury one of the following declarations: I have and will maintain a Certificate of Consent to self -insure for Workers Compen- sation, as provided for by Section 3700 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 required by Section 3700 of the Labor Code:, for the performance of the work for which this permit is issued. My Workees tT "Cvotmmppenns!attion Insurance carrier and Policy number are: �rRi t ` Policy No.: -1-A 0 O Carrier. CERTIFICATE OF EXEMPTION FROM WORKERS' COMPENSATION INSURANCE (This section need not be completed if the permit is for ono hundred dollars ($100) or less.) 1 certify that in the performance of the work for which this permit is issued, I shall not employ any person in any manner so as to become subject to the Workers' Compensation Laws of California Date Applicant NOTICE TO APPLICANT: If, after making this Certificate of Exemption, you should become subject to the Workers Compensation provisions of the Labor Code, you must 0 z forthwith comply with such provisions or this permit shall be deemed revo . ZCONSTRUCTION LENDING AGENCY " E -d tier I hereby affirm that there is a construction lending agency for the performance of (� i Ode work for which this permit is issued (Sec. 3097, Civ. C.) W A Lenders Name Lenders Address V C I certify that 1 have read this application and stare that the above information is LL, H cormCL 1 agree to comply with all city and county ordinances and state laws relating w 0 U building construction, and hereby authorize representatives of this city to enter upon the above-mentioned property for inspection purposes. W W (We) agree to save, indemnify and keep harmless the City of Cupertino against F -d liabilities, judgments, toss and expenses which may in any way accrue against said Cil) V Z in consequence of th granting of this permit APPLICANT U &STANDS AND WILL COMPLY WITH ALL NON -POINT SOURCJREONS. Signatureontractor Date ZARDOUS MATERIALS DISCLOSURE t or future building occupant store or handle hazardous materia as defined by the Cupertino Municipal Code. Chapter 9.12, and the Health and Safes; lodc, Section 25532(x)? Yes o Will the applicant or future building occupant use equipment or devices whic emit hazardous air contaminants as defined by the Bay Area Air Quality Managcmcr District? OYes *0 1 have toad the hazardous materials requirements underChapter 6.95 of the Califn nia Health & Safety Code, Sections 25505, 25533 and 25534.1 understand that if Onc buildin does not cturen ly have a tenant at it is my responsibility to notify the occupant of it reyuirementsllplch must t prior to issuance of a Certificate of Occupancy. [/ y. -9z n-. q Owneror aut ri d agent Issued b -i: Re -roofs Type of koof All roofs shall be inspected prior to any roofing If a roof is installed without first obtaining an it all new materials for inspection. Date being installed. I agree to remove Signature of Applicant Date All roof coverings to be Class 'N' or better