04040178 C TY OF CUPERTINO '� xwa*�a � F '�?•
BUILDING DIVISION PERMIT CONCRAC.TOR{{INk'URMATION ,
TO 3Y �&
BUILDING ADDRESS: TOENISKOETTER & BREEDING I MITNC04040178
10455 BANDLEY DR
OWNER'S NAME: PERMITISSUEDATE
bf, CHINESE CHURCH IN CHRIST 1960 THE ALAMEDA #20 06/15/2004
lip NE: SANITARY NO. CONTROL NO.
(408) 246-3691
ARCHITECT/ENGINEER: BUILDING PERMIT INFO
BLDG EIECi PLUMB MECH
trop LICENSED CONTRACTOR'S DECLARATION JS **pp ttfJJJ,,,���[t /� H rrr���
F I hereby affnm Nm 1 am licensed under provisions of Chapter 9(commencing Job-D, [21iA9, (I I l� O O
5ma`F�`� with Smlm]tln0)o(Division Sof HC Businessand Profession Code. rad mylicem ix tF I11I U 9/��N BLmfI�—s'
y in full force and Oct. (��l�p�a C! TI- -CHURCH
n$Z Licence Class r Lic,a
Z-p Dam Contractor 0�1
ARCHITECT'S DECLARATION
I understand my plan shall he used as Public mcnras oo/�
3 G� Licensed Pach ssi...I I�It D ryryry p r�'�,
S OWNER-BUILDERomp,from
DECLARATION �kl tI II tI (I �t���
F.a 0 1 hereby.('firm Nat I em exempt from the Contractors Coca:
License Low for the
my rlU IBJ Ct+L^a BBsY/j
F.p o following reason.Permit
t ](131.5,Business and om.derun Cale:AnY cityor county
$ which its i ms a pcnnit ac cors the der,im(.,m dcm.a or repair any atrunum $690000
priormicecemed c.m mm ntheasimun(forsuch Pcsmiuo Glcssigrednaemcm
(Mshcincingwith Sestina.He of Drvian of Ne Contractor's Licemlaw(Chap(tt9 Sq.F[. Floor Area Valuation
¢t-$ (commencing with Scetion]000)nf Division Sof Ne Businessend Profession Cale)or
y that he us exempt thonfrom and the basil far the alleged exemption.Any violation of
Seale.7031.5 by a,applicant for a p.I,subjects the epplieant in a civil penalty of
not mom thin lava handmd dollars a58o). a Occupancy Type
Lssawnerof the pmpnry,amy emplaned withwagesr is(Se. 044.BoeOon,
will do thcwork,endo: oroffiered Lawdos,formic
not c(Sm.to an,Bnerof
and Profession Code:The Connntofs License Law don not apply f an owntt is Required Inspections
property who buildsorimproves Hereon,ledwho doessuch anwart.101lef art ho ugh his
own wr.On Wilding
Nat such im is laid Within
are not inendcd oroRemd far Owner.
however.Ne W ildire or i en oamenn is sold within one year of mprowe for the owan
builder will have He burden of Proving that he did not Wild or improve for purpose of
sale.).
❑1.as owner of the property,am exclusively contracting with licensed xintracmrs to
convect the project(Sec.7044,Business and professions Code:)The Contractor.W.
ane law does not apply m in owner of propeny who Wilda or improve rcon
thc .and.
who contracts for such projects with a commands)licensed pursumtto the Communes
License law.
❑1 am exempt under Sn. .B&P C fm His reman
Own. Dam
WORKER'S COMPENSATION DECLARATION
I hereby affirm under penalty of perjury one of the following declaration: .
has and will maintain a Certificate of Consent to self-insure for Workers Compcm
.Nan,ns provided for by Section 3700 of the Labor Code,for Oma
e performance of the
work for which His p.i,is issued.
❑1 bout and will maintain Workcls Compensation Imran¢,as required by Section
37W of He Labor Code,for the performance of He work for which His person is issued.
My Workces Compensation Insurance canner and Polity number am:
Caniers�"I i' ?wAnGa•f✓ Policy No.: r
CBAPr TE OF EKEMY110N FROM WORKERS
COMPENSATION INSURANCE
(This section need not bocomplcmd if IM Icarnit isfmmic hundred dollarst51IX8
or Icm.)
1 cirdfy that in He Performance of He work for which His permit is blood,I shall not
employ any person in my manner W to become subject o the Workers Compensation
Laws of Califoorm.Data
Applicam
NOTICE TO APPLICANT.If,after making His Cenificam of Exemption,you should
become subject to He Wohcr's Comperwuon previsions of He Labor Calc,you must
,z forthwith comPly with such provision or His Permit mail be lamed rewound.
'Z O CONSTRUCTION LENDING AGENCY
't••� lhcr which iHat Hem isaco (Sce,3nl.Ch,agency for He perfunnana of
Om work for which Hu permit u issued ISce.J09i,Civ.C)
W Lsndr.Namc
]z 1<ndeis Address
fJ Q I door,that 1 haw mad Na application and state that the show infommian is
ly E' ConecL I agree to comply with all city and county on imcee and state taws mlaung to
�U building convection,and hereby authorim mpmsentaines of this city to enter upon He
abovcmemioned property for impaction whichmpurposes.
(r•'y (We)agree to now.indemnify and keep harmless the City of Cupcninas gainst
y liabRides.judgmenm,costa andexpcmn which may in any way¢true agaiw saidCity
n
t.J z in conuqucne.of the granting of this permit.
^' APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT Issued by: Date
SOURCEREGU TIONS
le�� Re-roofs
Sig. APPIinHAZARDO Dae
HAZARDOUS MATERIALS tsS m orhan l Type of Roof
Will He applicant or future Wilding acupant smrc or handle haalloes material
as defined by the Cupertino Municipal Code,Chapter 9.12,and the Health and Safety
ode,Section 255320)?
❑rex ON. 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
(hilmd"Ous air connotational as dcrined b the Ba Arca Air y g all new materials for inspection.
♦ y y Qaalil Management
iseic(?
C Yea ON.
I have mad He hannlaus mawrials mquimmenta under Chaper6.95 of Jon Celifor-
niaHcalth&Safety Cadc, dmu25N15.25533md2S534.IundcrsendH ifmc Wilding
does not currently haw a mount that it u my mapmadbili(y m pally the Occupant of We
rcquiremcnsswhlchmuubcmn taismanccafacmdfineofOccirip Signature of Applicant Date
�W'V //f 'K—�p,� All roof coverings to be Class"B"or better
Owner of mhoiind agent