05060123CITY OF CUPERTINO1:'.�«„a.
BUILDING DIVISIONPERMIT
CONTRACTORANFORMATION ', ;
BUILDING ADDRESS:
PARK PLACE CONSTRUCTORS IN
ERMITNo0S06012
10110 CALIFORNIA OAK WA
Wits NAME:
PERMIT ISSUE DATE
PG & E / METRO PCS
S4O S 12TH STREET
2005
PHONE:
SANITARY NO. CONTROL NO.
(S10)233-0257
ARCHITECTMNGINEER:
BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
0 0
LICENSED CONTRACTOR'S DECLARATION
Job Description
1 hereby affirm that 1 am under of Chapmr 9 (mmmcncing
[]
Procus
with Sectlon 7") of Di g'¢ion ]ofd¢Busimssarrd Profecdem Codl and mylicenw is
of the Bu and
-
infull force and ral'oX. { 1( 2d 8So
REVISION --ADD NEW METER
License Class Lica
Dole �e ConuacbmCQAT1.b
NO NEW PERMIT ISSUED/ORIG. 40SO1O044
ARCHITECTS DECLARATION
1 understand my plans shall he used as public becmds '
Licensed Professional
OWNER -BUILDER DECLARATION
1 hereby affirm that I am exempt from mm Contmno's License Law for the
following reason. (Section 7031.5, Business and Professions Coil Any city or county
which requires a Permit In construct. alto,, improve, demolish. or repair any structure
prior to its issuance. also rtqu res IW applicant for wch peoniOo file a signed sutcmem
months, u licenmd,tw uLto the provisionsOftho Contractor's Liecom Low(Chapter9
Sq. Ft. Floor Area
Valuation $0
(commencing with Section ll") of Division 3 of Ne Businessdnd Pmmxwom Cwm) m
that he is exempt Ncmfrom and the basis for the alleged exemption. Any violation of
APN Number
Occupancy Type
Section 7031.5 by any applicant for a Permit subjects the applicant to a civil penalty of
nm mase than five hundred dollar$ (M).
34263001.00
0 1, as owner of the property, or my employe" with wages as Noir sole compensation,
Required Inspections
will do the work and the structure u no'inonMcd or offered to, sale (Sec. 1814. Businm
and professions Code: The Conuacwr$ License law does wt apply m an owner of
progeny who builds orimproaes Nercon, and who docssuch work himwlfor through his
own employees, provided that such improvements are notinonded or offered for sale. IL
however, the building or improvement is sold within one year of completion, the owner -
builder will have the burden Of proving Nal he did nal build Or improve for purpose Of
bale.).
�\
0 1, as owner of the propony. r m exclusively cassuming with licensed mnvacum to
customer use project (Sec. 1()14. Business and Professions Code:)The COnmachers LI-
�^
cene sLaw does not apply to an owner of properly who Wilds or improves daemon. and
`l
who contracts for such projects with a contractor(s) licensed promisor to the Contractor's
License low.
0 1 am exempt under Sec. . B h P C for Nis rtazon
Data
W. WORKER'S COMPENSATION DECLARATION
1 hereby affirm under pe.tiny of perjury nuc of the following dwarmi us:
0 1 ham and will maintain a Cenifiew, of Contin to self-im rte for Warmer COmpen-
sition, as provided for by Section 3700 of the IJWr Code, for the performance of rota
wort for which Nis Permit is issued.
have and will maintain Worker'a Compensation Insurance, as re piimd by Section
of me Labor Cod, for the performance of Ne work for which this permit is issued.
My Worker's Compensation Insurance carrier and Policy number am:
CarierT0pe6u Policy No.:a12..flWlgf
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(This section need not he completed if the formyl is furore hundred dollars (SIM)
or less.)
1 cenify thus in the pcnN mai es of Jas work for which this Permit u issued. l shall not
employ any pawn in any manner an u m become subject to tho Worksho Compenotion
Laws of California. Date
Applicant
NOTICE TO APPLICANT. If. after making our Certi0cam of Exemption, you should
become subject to the Worker a Compensation pmvisions of the labor Code, you must
forthwith comply with such provisions or this Permit hall he d"med revoked.
CONSTRUCTION LENDING AGENCY
1 hereby afro Dont there is a construction lending agency Inr the perfurmanm of
the work for which this permit is issued (Sec. 3037. Civ. C.)
Lender's Namc
Lender's Address
1 certify Na 1 have read this application and sole that Ns, shove information is
cortctt I arm m comply with all city and county ONinances and some laws bell to
building construction, and hereby authome representatives of this city in enmr upon Ns,
abovcmemioned property for impecdon purposes.
(Ws,) agree to save, indemnify and keep harmless the City of Cupertino against
liabilities, judgments,costs and expenses which may in any way accrue againatwid City
in comequcnce Of be granting of this permit.
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON -POINT
Issued by: Date
SOURCE U
- 6�Zd(dt
Re -roofs
Type of Roof
�It, GP icant1Conlmcmr Dam
�/ HAZARDOUS MATERIALS DISCLOSURE
Will The applicant or future building occupant mom or handle havardous material
fined by fhe Cupertino Municipal Code. Chapter 9.12, and the Hcalth and Safety,
0Y,sss]z(an
All roofs shall be inspected prior to any roofing material being installed.
El No
If a roof is installed without first obtaining an inspection, I agree to remove
Will the applicant or future building occupant sew equipment Or devices which
coil havardous air contaminants as defined by the Bay Arca Air Qualify Management
all new materials for inspection.
District,
C3 Yea 0 N
I have read the banrmoua materials mqu reamots under Chapter 6.95 Of the Califpr-
niaHeallh&SafetyCode.Sectio 25505,25533 and 25534.1 understand thus, if the Wilding
do" not curcn0 hose a Nat it is my rusponsihility w notify the asupent of the
roytr;re,rtn t morcel imacensficam fOcc q6,
Signature of Applicant Date
/Dam
All roof coverings to be Class "B" or better
(/
owner
or,mohnrived agent�_