00060114 'CITY OR COPERTINO a
nutcowC.DIVISIONpERVIIT CONTRACTOR INFORMATION:
" EUILDING ADDRESS: _ " •1' PERMIT NO.
r OWNER'$N P : .w y• - .. 1! APPLICAT
1. r�'76C1 ARRTA„WAY WWQT�1.
IONS: ` SANITARY C 'f c NO'
/46
MRRTINEZ,. SA
. RICHARD cM
Mot ARCHITECTIENOINI LR: - - , Ar13111LDIM PFIIMI'I'INFO
EIAC ELECI1 PLUME MECH
F-�Z ' LICENSCD CONTRACTOR S DECLARAl10N
i?z
I rech,liffindmatIrl ],,,.,ad de - IChapter 9(eouueP ag r JobDescinption
a (rB
with Section]oIXp fDaemon3uf In,en d Profeesions Code red DIY f _ - — ` •.` .
is in fail Interact]offro. N
w ee� nx
C Llcer Class - L it
It.
Crantracter
u S Data ARCHITECT'S DECLARATION Y TEMPORARY ,.POWER .
I and (add nlyp -h ll beused poll records, -
wrf r
Irl�cit
O J."aricedF fier,ional OWNER eUILDCR DECLARATIOO
N
I;h by [f ❑rat 1 it.,various t due Candri 1.1h,far the - b
Zjdbribrivi6 hoond.(Section 71315e . dProfession,CdeAryaYt
which q Yu county
L S C 1 p u :rtItp dI:IIy structure
w prat I ''. a al. q ' .rl pp[ tf hp 1t 11 ' tt
'y- I Hent •' '< ;,
s he,he,,licensed andurntt tire prot ofti r s Licani L (Chapter 9 Sq. Ft.'Floor Area _ - - '.Valuation.', -
ho dente,with Sect 7000) I D' 3 r d 9 : d 1 f Code) -
orthat hea enpuh coreand tire hai forme ulle6ea coenpton.Ary,Iolnan -
or not
9411 5 by an,hundred
cam fes( permit,ubJems me upPlinlm m a anvil penalty ,
' arnarldnremanfivennndreaaanam1851n). � r APNNumber - -.Occupancy$'Ibpe - -
•1 - 1,
° y
I,as owner of the property,or dr In h o
with (her,,)In tom 'don,
. ill d d irk and th �t on is t of d le J r I (See.7044, " e
Is a add 1 fe! Chad.TI C tar :I 1 J l apply In an - Vquired Inspections '
r p p dy Wn n d(b, p .mean and wh d k l m,ell' 37501561. DID' ,
or d uyh lis own emploi provided that such i n onto ns em nor' tended or
offered for solo If however,the building t is 1h bane of
1
ouplefon the owaseb Tl -IT ,vr
hthe border ofn pngd t heard air,boom or
3 _ 304, - "
hnpmvo for Purpose of ' ` ROUGH. ELECTRICAL -
❑La,ownernfineprnpe" 'adexcld.i.ely nmrnalinswhn deIIheConrrct rn.. 50i. F1 NAL, ELECTRICAI_ ,ENERGY
construct project(s 7(w e . aProfessionscdJTncrt3eto(, 505 •.- FINAL ELECTRICAL_
License t J c. pI ly t - property h IJ r' p :thereon
and h contracts fir aeh p,9ecls with rntnrth r(e) licensed pursuant m the
Contractor sLicense Law. -
❑Iame,enyttnderSe &P C of ba,rtes..
WORKLI COM1IPENS\TION DECLARATION
ver I hereby afrlrm ander penalty of perjury oda of the following dcclrmtions - - "f000
..
_ V r.
❑ I have and will n a C I aIC C nt I If l W dere t ), �R ,
Compe f : p J f by S 3700 f th L b Cul f r rhe
pert f fi k f h'h this I s issued. _ - /��
°Ihave d ,It dooddi a'captured bySelln
3700 of rhe Labor Cole for he paikendY ce of the were for con rh this pend L is -
isaued.My Workers Condpmual c Insuranec carer and Policy nmnner aero _ W
. -
Carried - Palicy,No,i I ' r 1. - - • h
CERI'119CA'1']ON OF EXEMPTION FROM WORKERS'
r COMPENSATIONIN URANCIi -
(Ths se m need dor be co irplard if lnepe-nf',for me handrul dollar,
(510oJ I. )Lir - �.
I certify that in the pefrnume rf the work for which this perm is isided,l r , tri
-shall nor court, ' nor ao av m haconrn suh eco t the Worker,
any person m any ma ,
cn.rdnlil
n Lowe nl'Canrnix Dore
Applicant
'
Applicant - 5 r r
NOTICE N APPLICANT
QUO aR k b C enrol E prI y houd
it Worker rC p . t this
t ole Late Cod y mel
palliation entirely chp is onsorm pe rshull helocated re
- r -
Fr~4., - CONST RUCTION LENDING AGENCY
a,' l hi nffum that is r ennstm'don lending agcncy for the parinrmance
W ti of the work for Is Inch tht,pardi i, ood(Sot.9097.Ctv.C 7 -
QLender's Name _
z Isnder,Address
Irenily Par l have read this idication tendstt hat the h information is r t
W H t)rwcr I agree to coriply with all cityand worry olidlid'fail lI I g
Q V to building doemorationa,;,adthereby dintrazt, epassentatovesIt this city t to p • l ' '
04 men f Property I P c( p ha a ,
Wuhi[ (W) g t i, rd f) adpl le,:m CtY TCP tg ' .t
V
City n c m eq ante of the'rearm,d IN P nd t.,Zj it Y any way e ayu ry 'A .
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-PDINT
souace orvsilj Issued by: Date
if
Slg real Applic ru uand Cx ` +. '•A— pate • Re
7roofs
IIAZARUOU 1A GRIALS DISCLOSURE
Will the xppfieater or furore building oner"an Stara we handle lraeuAous oderi.] Type of Roof
- as defined by the Cupu3ina Mannered Code,Chapter 9.122,and the Thai and Safely
Cade,Section 25532(x)'!
Ely
as °NoAll'roofs shall Lie inspected prior to any rooting materialbeing installed:
Will the applicant or future building recreant use equaunepl to doo,ro,which If a roof is installed without first obtaining-an inspection;I agree to remove
mit hazeMous as c do drioants a,defined by the Ray Are;,Air Quality Muns,con, l -
trea1l all new materials for'inspection:,.Applicant understands and will comply with ` 4'
El Yee, - [I No - all,non-pomrsource regulations,'
I have read the learned ous materiel.rcquiremenls nndeF Cbxprer 6.95 of rbc - -L e
Wlifmtralledlth&Saf"ryC de ....125505.25533and 25534,1 understand[hit -
If the buildingd snot art dyIv nen 'ttl that nryPel I.'n'I'yi notify the -
scup f thequiry n t: lbich must be t prior to tidiance or a cerlificaboof "1'-
°c`p . Signature of Applie"t Date.
own r or authorized aselr! ' ,�' Date, All roof coverings to be Class B' or,better ' -
a
OFFICE
CITY OF CUPERTINO
BUILDING DIVISION PERMIT CONTRACTOR INFORMATION:
BUILDING ADDRESS: PERMIT NO.
OWNER'S N APPLICAT
1.41 60 ARfiTA WAY � �T�.14
_ c PHOrTB: SANITARY& Cp T NO.
===
MARTINEZ, RICHARD
�i,6f�t�t��
0 n Z ARCHITECT/ENGINEER: BUILDING PERMIT INFO
Cm BLDG ELECT PLUMB MECH
Qzvz� O O o 0
�Q�
F. LICENSED CONTRACTOR'S DECLARATION
Z Z I herebyaffirm that I am licensed under provisions of Chapter 9(commencingJob Description
Z. O P Pe
j with Section 7000)of Division 3 of the Business and Professions Code,and my license
p414�
is in full force and effect.
a w¢ License Class Lic.#
a U Date Contractor
O¢
ARCHITECT'SDECLARATION TEMPORARY POWER I understand my plans shall be used as public records
o0 Licensed Professional
� OWNER-BUILDER DECLARATION
m n rn I hereby affirm that I am exempt from the Contractor's License Law for the
4< following reason.(Section 7031.5,Business and Professions Code:Any city or county
Sa 0 which requires a permit to construct,alter,improve,demolish,or repair any structure
prior to its issuance,also requires the applicant for such permit to file a signed statement
3_ that he is licensed pursuant to the provisions of the Contractor's License Law(Chapter 9 Sq. Ft. Floor Area Valuation
(commencing with Section 7000)of Division 3 of the Business and Professions Code)
or that he is exempt therefrom and the basis for the alleged exemption.Any violation
of Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty
of not more than five hundred dollars($500). APN Number Occupancy pe
1:11,as owner of the property,
p perry,or my employees with wages as their sole compensation,
will do the work,and the structure is not intended or offered for sale(Sec.7044,
Business and Professions Code:The Contractors License Law does not apply to an ,+D�,equired Inspections
owner of property Who builds or improves thereon,and who does such work himself _: - ',mac–TQC—(i)K.t
or through his own employees.provided that such improvements are not intended or
offered for sale.If,however,the building or improvement is sold within one year of
completion,the owner-builder will have the burden of proving that he did not build or ;.�, — ROUGH ELECTRICAL
improve for purpose of sale.).
❑I,as owner of the property,am exclusively contracting with licensed contractors to 501, ` FINAL ELECTRICAL ENERGY
construct the project(Sec.7044,Business and Professions Code:)The Contractor's n1
License Law does not apply to an owner of property who builds or improves thereon, 505 FINAL EL EC T R I C.,AL_
and who contracts for such projects with a contractor(s)licensed pursuant to the
Contractors License Law.
❑I am exempt under S ,B&P C for this reason
ner Date '�'�f AGO
WORKEIV COMPENSATION DECLARATION /
affirm I hereby am under penalty of perjury one of the following declarations: 6 ///��
❑ I have and will maintain a Certificate of Consent to self-insure for Worker's `//`• l
Compensation, as provided for by Section 3700 of the Labor Code, for the
performance of the work for which this permit is issued.
❑I 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 Workers Compensation Insurance carrier and Policy number are:
Carver. Policy.No.:
CERTIFICATION OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(This section need not be completed if the permit is for one hundred dollars
($100)or less.)
I 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 Worker's Compensation provisions of the Labor Code,you must
0 O forthwith comply with such provisions or this permit shall be deemed revoked.
H CONSTRUCTION LENDING AGENCY
I hereby affirm that there is a construction lending agency for the performance
W of the work for which this permit is issued(Sec.3097,Civ.C.)
A Lender's Name
a z Lender's Address
V 0 I certify that I have read this application and state that the above information is
w H correct.I agree to comply with all city and county ordinances and state laws relating
0 to building construction,and hereby authorize representatives of this city to enter upon
FW the above-mentioned property for inspection purposes. f/
a (We)agree to save,indemnify and keep harmless the City of Cupertino against
H fA liabilities,judgments,costs and expenses which may in any way accrue against said C—Z
V 4 City in consequence of the granting of this permit.
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT Issued b Date
SOURCE ONS ` O,� y'
c
Sig re of Applicant/ ntra or Date Re-roofs
HAZARDOU A RIALS DISCLOSURE
Will the applicant or future building occupant store or handle hazardous material Type of Roof
as defined by the Cupertino Municipal Code,Chapter 9.12,and the Health and Safety
Code,Section 25532(a)?
❑Yes 0 N All roofs shall be inspected prior to any roofing material being installed.
----- 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
emit hazardous air contaminants as defined by die Bay Area Air Quality Management
District? all new materials for inspection. Applicant understands and will comply with
--_ ❑Yes ❑No all non-point source regulations.
"-' I have read the hazardous materials requirements under Chapter 6.95 of the
California Health&Safety Code,Sections 25505,25533 and 25534.1 understand that
if the building does not currently have a tenant,that it is my responsibility to notify the
occupant of the requirements which must be met prior to issuance of a Certificate of
Occup Signature of Applicant Date
caner oauthorized agent Date All roof coverings to be Class `B"or better
OFFICE