07120263 CITY OF CUPERTINO
BUILDING DIVISION PERMIT sCNTRAGTORANF�ORMATION
PERMIT NO.
BDILDinalb"StALVERT DRIVE TBD - TO BE DETERMINED 07120263
d'$NAME: PERMIT ISSUE DATE
BILL SULLIVAN 05/28/2008
PHONE: SANITARY NO. CONTROL NO.
ARCHI3EC(ENGINEER: BUILDING PERMIT INFO
-BLDG ELECT PLUMB MECH
lee,
LICENSED CONTRACTOR'S DECLARATION Job Description
a 1 hereby affirm Nal I am licensed under provisions of Chapter 9(commencing
with Section 70M)of Division of the findncu and Professions Code.and my license is REMOVE EXSTNG 800 SQ HOUSE & CONSTRCT NEW 2344 SQ
n full fora and effect.>q_ License Clau Lk.• SFDW
F O Dole Caribbean
e£yW ARCHITECTS DECLARATION
ndm
tl C< 1 ueand my plans shall W used as public records
JyU
age j r^ Licensed Professional
a� OWNER-BUILDER DECLARATION
f 1 hereby.from that I am exempt from the ContncmYs License Law for thc
p O following won.(section RD 1.5,Business and Profession.Cole:Any city ar county
which squires a permit a crmwuteL alas.imp ow.demolish,or repair any structure
i y prior to its issuance.Alan requires the applicant for such Permit o file a Signed sute.ent
< that heuliccuredpursuanttothe provisions ofNcContractor's LicenseLaw(Chaptm9 Sq.Ft. Floor Area Valuation
i�C (commencing with Sccuon7000)of Division 3 of the Badness and Prof.sio.Cads)or S4000OO
E R$ that he u exempt therefrom and Ote bun for on alleged exemption.Any violation of
Sued..7031.5 by say applicant Tor a permit aubjccu on applicant fa a civil penalty of _T7_518 06�N Number Occupancy Type
set seam than five hundred dollars($500}
❑1.u owner of tite property,a my employe.wIN wages ss Ne'vmole compensation,
and dothewah.andtheon come.
does,
and ppty in a4,eusieof Required Inspections
and R ywho ns Cods The eanlrKmra License ms Baa ser apply lf r ave h of q P
minicnywho builtls oimpmmch imn,.as.Is am mA i hwmle himself ea Mough hu
ownemplaymsip in gor aonowmimp.wmmuase not leadedmoaestl are O e.lr.
hOwarr,Ne Wildinghaier ofpr tVsWdn,dhinarc year or completion,Neower-
builder will terve tier Nudan of paving Nat In,did rat build or improve for purpose of
sok.).
1,an aver of the pmpeny am exclusively contracting with licensed comrxwra m
co.t.cd the project(Sec.7014.Business and Profession,Code:)The Contractees Li.
cense Law doer not apply in in owner of property who builds at improm thermn.and.
who contracts fm such project with a contramar(s)licensed pmaunt in the Contractees
L'anse Law.
m exam/pywoda Scm B 8 P C for Nu maven
c:r / 7 'Date 5 ' iti• C
WORKER'S COMPENSATION DECLARATION
1 hereby affum under penalty of perjury,arc of the following declarations:
Q thaw and will maintain•Certificate of Ca.ent N self-insure for Worker's Compen-
sation.provided fm by Schon 3700 of the Latest Code,far the performance of the
wale for which Nis Permit is issued.
❑1 have and will..lawn Workers Compensation In aance,as requited by Section
3700 of am labor Code,far six preform.of the were,for which this Pemtit or iuuW.
My Warkees Compemation Insurance airier and Policy number are
Cartier. Policy No.: '
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
mussecdon need not be canpleted if Ne permit is foeane t undrtd dollars(5100)
or leu.)
I certify Nat in the performance of the work for which this permit in brand.l shall not
employ any person in any an Warsras'Compe.adon
Iswao'Califomia.Dam-- 1 a I•
Applicant
NOTICE TO APPLICANT:IL afar making this CeNficate of Exemption,you should
become subject.the Workcfs Compensation p.visions of the Labor Codes you muse
,J O roMwith comply with such provisions or Nu permit Shall be decreed unrelated.
z" CONSTRUCTION LENDING AGENCY
r F
I bunchy aOiem Out Nm is a construction lending agency for Nc performance of
On wok fur which this permit H issued(Sec.3119'/,Civ.C.)
0.. 0 Lsnder's None
.7 z Lender's Addw
U O I caury Nat 1 Nee read this application and sum Nm tiro above infomation u
gy!' torten.l agree to comply with all city and county oNim.andmute tan slating u
O building convection,and hereby authorise mpossenutim of Nu city m enterupon the
tr cShow-mentiaed property fa inspection purynses
(Ye,)agree to on.indemnify and kap hardeless the City of Cupertino against
r/5 liabilities,judgment.costs and e.pnnus which may in any way acenr ag.I.r to City
Uz mcmeacquem.of Ne granting of this permit.
^� APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT Issued by: Date Z dl_r
SOURCE REGWTI NS.
Signature ar if wtucunu,m'1 ' —� p� Re-roofs
HAZARDOUS MATERIALS DISCLOSURE Type of Roof
Will Ote applicant or faros building acupantramo m asur le hanrdaus mural
Rad by ae Cuprtim Municipal Code.Chapter 9.12,and Nu Hata and Safety
SmOom` 0Yen 255324)? ❑No All roofs shall be inspected prior to any roofing material being installed.
If a roof is installed without first obtaining an inspection,I agree to remove
Will Ne applicant or future Wilding Occupant sew equipme.or Bevis.which g
craft hanrdous air contaminants as defined by the Bay Am.Air Quality Management all new materials for inspection.
District?
❑Ya 0 N -
I have sad the Inuardous mwuials requirement under Chapter 6.95 of theCalifor-
ria HealNhSafayCodeSmvoa25505.25533 anal 25534.1uMcnwE Na if the Wilding
does not currently how a tenant Our it u my sspansibility to notify the wcupam Or am
reyulmmenu m bemmpi- ora issuanm or Ceni5te.— 7— vpaay.
�u,Met poor
J _ Zs - Gs Signature of Applicant Date
.Owner Or authorized Agent Date I All roof coverings to be Class'R!'or better
_ — 1.