04070058 CITY OF CUPERTINO %"° '� non ••' '�'" �•t" "-
BUILmNG DIVISION PERMIT CONTR`AC�TOR INFORMATION
BUILDING ADDRESS: PENINSULA BIBLE CHURCH INC PERMIT NO 04070058
OWNER'S NAME: PERMITLSUEDATE
E: SANITARY CaMROL NO.
ARCHITEC(ENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
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y0C LICENSEDCOmmed unDR'SDEConsof CON ® ��®
m I Wreey affirm wt I nn Raved tines PmvivOns m Chapter 9 commencing Job Description �/p�f{af9U
iWR with Sxrce ndc(ofDivision lofty Busircmw Aofessiov Code.orb my license is
n<n, in full fora and drat
3'qi Lima..Cl Lie.Is TI--CONVERT CLASS RM TO OFFICE
Dab Conlncbr V ZUU4
�i I undcatand my plans shall he used u public records ATION ��"
oats yy��
;off Licensed Professional ' ®��®I�
OWNER-BUILDER DECLARATION ,e■Q✓tl®
f I hcrchy afrinn
that 1 am ucmpt Item w ConuacmYs License Lew for IW V
00 following reaon.(Section 7(01.5,Business and Prfessiuv Code;Any city or county
x$f. which requires a permit to cnvuua,a@r,imprnw:.demplish.in repair My structure
prior in its issuance,also require lW applicant for such permit to rale a signed statement
LSC
that Walicensed purmanttoMepmvisiovofMe, Law Sq.Ft. Floor Area Valu tion
ms- (commencing with Section 7000)of Division 3 of the Burins and Profrasiov Curie)m
y $
that W is uerem thertfmm and tie basis for the alleged exemption,My violation of
Section 7031.5 by arty applicant for a Nmmlt subjects the applicant to a civil pevaty of 3 Y$Dl2'btS�erO 0 Occupancy Type
�no7not thn rave to ndom amlibrat($5oo). P Y YP
{+J 1,as nume,of db P.Pwy army cmployxu with wegv a their tele compensation.
will do Ne work and Ne+wcture isnotimended oroQertd for%Me(Sec.7014.Business
and Professions Code:The Contractor's Liave Law do not apply to an owner of Required Inspections
property who builds or Improves thereon,and who does such work himseif or through his
.we employees,Provided Nat such improvements are out intended oroRercA(orale.If.
however,Ne building or improvement is sold within one year of completion,Ne owner.
Wilder will have the burden of proving that W did not Wild m impmve for purpose of
rale.).
0 1,as owner of Je propcny,Me eaelmocly cpn ossau,wit headed anuacbrt to
construct the prejcm(Sec.7066,Beat..and probations Code:)The CommetoY+Li-
cemel=.j,. (Y)'I=d'=Pm=Cm.0nwe1
owner or propenY who Wilds orimproses Mertonandwho covi ntrmmrtgliceraud pursuemmw Cnvactofs',BAm m.0nwenbOMPENSATION DECLA ON
1 hereby affirm under Nulty of perjury one of the following dela ethms:
la,and will maintain a Certificate of Consent in self-insure for Worker's Comped.
station,m provided for by Section 37M of the IaWr Code,for w performance of Ne
work for which this Permit is issued.
0 1 have and will maintain Worker's Compensation Lonna,a requirtd by Section
3700 of the Labor Code,for w pmfarmnce of be wools for which this permit is issvd.
My WorteYa Compensation Imurarec timer and Policy number art:
Cartier. Policy No.:
CERTIFICATE OF EXEMP ION FROM WORKERS'
COMPENSATION INSURANCE
(This section need not W complewd if the permit isrmo a hundred dollars($IW)
or less)
1 anify bot in the performance of the work for which this Permit is issued,l shall not
employ any person in any mnocr u az w Meomc subject to Me Workers'Corporation
Laws of California.Date
Applicant
NOTICE TO APPLICANT:If,able,making this Certifies¢of Exemption.you should
Weome subject to Ne Woher's Compensation provisions of Ne Labor Code,you mum
.J,z forthwith comply with such Prevision or Nu permit shall W deemed rcvokcd.
Z O
YN.. CONSTRUCTION LENDING AGENCY
(hereby affirm wt thuma lending ager
for the
perfomancof
Le work for which the permit is ima0(Sm.3D97,Civ.C.)
Qnder's Name
5 UZ Under',Address
V 0 1 cenify that 1 him read Nis application and sate bat theBreve infonnatiun is
L,, P cornet 1 agme to comply with all city and county ordinances and same laws baring to
V Mmetngcohomed on, try nd
iya cdofinnp rcprescnutives of this city mentor upon the
yshove-mend filo onroc tori cuan putPoses.
(Wc)agrte tp ave ify and keep harmless IN City of Cupertino against
h ii coiamance of
ntl ' ichmgin MY Way ettrc again,aid City
t)z in conuqucnc,of the tin of s r 'I.
^ APPLICANT UN RST DS OMPLY WITH ALL NO POINT Issued by:%121 Date
SOURCE TIO
-Ofr Re-roofs
mgnmusc of 0 mUComuamor Da
HAZARDOUS MATERIALS DISCLOSURE Type of Roof
Will be applicant or future Wilding occupant mom or handl,baaandous material
as defncd by the Cupertino Municipal-Code.Chaper 9.12.and the Health and Safety
Code,Section 255320)T
❑Y. l00 All roofs shall be inspected prior to any roofing material being installed.
If a roof is installed without first obtaining an inspection, agree to remove iection,I
Will the applicant or future building aceupam use equipment or devices which p
istlrluminous air contaminants m Jcfincd by Ne Bay Area Air Quality Management all new materials for inspection.
0 Ycs
I have rtad Me"um'
aerials monis unties Chapter 6.95 of Me,cable,
m.1-1.1 th&saretycndc 25505. 514.1undcrmaM thmiftM Willing
Jo tet curneml a '¢n t wt t ibdity m notify the upart or the
mquiremontswhi secs aCerifieeof qx ry
(S! ® Signature of Applicant Date
own, amhod a agent ab All roof coverings to be Class "B"or better