08080095 CITY OF CUPERTINO -
BUILDING DIVISION PERMIT CONT"C-TCTR�INF,ORMATION �4
L'�,.93•'v `W!$....=
BUT IN44A DRESS: PERMITNO.
�03�0 BUBB RD TBD - TO BE DETERMINED 08080095
41 NER'S NAME: PERMIT ISSUE DATE
HOME OF CHRIST CHURCH 09/08/2008
PHONE: SANITARY NO. CONTROL NO.
ARCHITER/FNGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
COO LICENSED CONTRACTOR'S DECLARATION O O O
F 1 hvaby StRnn that I am licensed under provisions of CNpar 9(rommcreing Job Description
O with Section 7")of Division 3ofthe Business adProfessions Code.and mylicense e TWO NEW HANDICAP ACCESSIBLE STALLS ON (E) 2ND FLR
in full force and Clfem.
�
qz LlccvseChau L'c.e KC-DESIGN BUILD LLC PD' FOR BUS LIC 8/13/8
^F q Date Commctor
ee 7W ARCHITECTS DECLARATION
; u I uUMUCmd my pWU MVI W sad u public records
io
I;n t; Licensed Prufesumbil
'0 01 OWNER-BUILDER DECLARATION
i�E 1 bereby affirm that I am exempt from the Convenors License Law for the
COO following mean.(Section 7031.5,Business and ProMisiom Code:Any city at county
S 3 ff which helium a pmmt in com erect Sher,improve,demol W,or Mi nir any constitute
Priv he its ismMI also moon.theSppliant for Such permit he Rle.unned==on,
pp that he is licensed pursuant to Ne provisions of the ConvecwhLicense Law(Chapter 9 Sq.Ft. Floor Area Valuation
Y�9 (commencing with Section 7000)of Division 3 of the Business and professions Code)or $10000
that he is exempt thert(rom and the basis for the alleged excepal o.My violation of
Section 7031.5 by my applicant Por a Permit Subjects the applicant to a civil Penalty of
rot mom Nan five hundred dollas($501y. 35720109 .Number Occupancy P Y Type
❑Las owns of th PoPertY.m mY wplayen wW w.gn a Ne'v role mmpenathan,
will da the wart and IW sSeC on is natNtended er a w does
set a(Sec.n son Basi r of
ane ernywh mu Cage:mp Canl n.License law area not apply N an owner of _ Required Inspections
owner WWWilda oimpro as such imnive a is ad not intwmkhimxlfmtluoSle his
hmm m,.Me W,Provided Wilding
orsreprommimproveman ii.m.intended ooRered for mane.
however,the am ti e b r ilea omovingent taidIm did arc you orimpro a for no manse.
Wilder with bow the Wrdan of poling Nat Int did rot Wild or impose far puryose of
ale.).
❑1.as owner of the property,an exclusively cmarm n,with licensed mntrxNrs he
comuea Me Mica(Sec 7W.Businea and ProfessioM Cade:)M Convaewh U.
mrue raw dors not apply in a ower of property who builds or improves that on.ad
who Concocts for such projects with a conuacwr(s)licensed pursuant be the Cantrachoes
License
❑Ism w tunderSm ,Bh PCfenthis n
D.te 4 c8
WORKER OMPENSATON DECLARATION
1 hereby Num under penalty of perjury,one of the fallowing declarations:
❑I him and will maintain a Certificate,ofConuent to self-Insome pnetim ors Con am.
sstion,ss provided for by Section 3700 of the Labor Code,for the performance of the
wok for which this permit is issued.
❑1 have and will maintain WhI Compemuon Insu I as required by Section
3700 of Me labour Code.for Ne performance of the work forwhich Niv permit is issued
My Workers Componsaim Insurance Cartier and Policy number art:
Caller. Policy No.:
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(TTM section need nothecompkied if IW Permit is nae.handed dollars($I00)
or less)
1 certify thvt in performance of dm rock fo which is
permit u.M^•r,I shall not
employanyp eNY mNOersa L{bbl.•mmC iebjCCI N Ne Warkers�Compena'Ion
U '="
Appl mm 11
NOTICE
To A :it. mating MIS Cer6Rcate of Exemption,you Should
become subject w the Workers mpmilion provisions of the labor Cede you most
.,O forthwith comply with such perineus or Nu permit Nall be dmreared.
ated.
zN CONSTRUCTION LENDING AGENCY
[—m I hereby affirm that them is a conswcu^n lending agency for Me perfmmance of
C' the work for which this permit ti iaucd(Sec.3091,Cir.C.)
14
Q finders Name
0.,Z Lcndeh Addess
f,J Q 1 ceaifY Nal 1 him mod this appliCSUM and SUM that the above information Is
w fr maCCL 1 agRC N Comply with W City Nd county ordi Ci and sate laws mating N
building camvunion,and hereby authorise Mpnmmundws of this city N color upon the
H4v above-,rat ommd property for inspection purpmes
(We)agree to nm,indemnify and keep harmless the City of Cupertino against
y Iiab1114Ci judgmenu.C.and exp-...whim may N any way accrm resimt aid City
V z in Cmdxmxcnce of the grating of this permit
^ APPLI ANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT Issued by:91tojAa Date
S0U UL.ATIONS.
�gi o$ Re-roofs
uu /
Smenof pplmnnUCa wr Dale
HAZARDOUS MATERIALS DISCLOSURE Type of Roof
Will the applies o in future Wilding occupantuere or handle haardous material
as defined by the Cuportim Municipal Cod:.Chapter 9.13,and Ne Health and Safety
.Section[IY.2ss32(.)7 All roofs shall be inspected prior to any roofing material being installed.
[I Y. f7eio
Will Ne, Ikons our future building occupant ase If a roof is installed without first obtainingan inspection,I agree to remove
PP e e equipment or devices which
�Shavardous air cmuminants u definW by the Bay Area Air Quality Management all new materials for inspection.
❑Yrs Ire
I have mad She huardoa m scrials mqui camas under Chaplorb.95 of the CSI
ria HcalNk Safety Cede,Sectors 25505.25533 Sad 25534.1 undo .d malifthe WiWing
docs not currently Mm a Moret that it is my responubility to merry be omupar of She
require U. bmost W met piorw iuemce of a Cu rf of OcCvpanry.
411ignature of Applicant Date
S
Owner our eth . n Dow - All roof coverings to be Class apse or better