03120082CITY OF CUPERTINO
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BUILDING DIVISION PERMIT
CONTRACTORA FOitMATI®N��
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BUILDINGADDRESS:
ROCKWOOD CONSTRUCTION CORP
P�"MITND03120082
OWNER'S NAME:
PERMIT ISSUE DATE
2
NE:
SANITARY NO. CONTROL NO.
ARCHITECrfFNGINEER:
BUILDING PERMIT INFO
BLDO ELECT PLUMB0 MECH
0 0 0
LICENSED CONTRACTOR'S DECLARATION
Job Description
p
I Mrtby affirm that 1 sm licensed under provisions of Chapter 9 (cemmmeing
withSec on7(3(10)af Divisioo3ofde Bwtocsra Pmfcuians Cade. and my license is
in full fo and effect. 14
L;eemSa . �_L]..a -65L - ,
REVISION --IN HOUSE USE ONLY
Da
NO NEW PERMIT ISSUED/ ORIG. 403070085
ARCHITEConOractor,u,—nrloN
CPSI t&ri qnJ my plans shall tl es public rtcgr!
Licensed Pf I
NEROUILDER DECLARATION
1 hereby affirm that I nm exempt from the Conlrsemr's Licene Law for the
following mason. (Section 7031.S, Business and Professions Code: Any city or county
which requires a permit to construct, alter, improve, demolish, at repair any struenure
poor to its Issuance. also Rqulres the applicant for such Permit to rile a Signed statement
that W is licensed pursuant to the provisions of the Contractor's License Law(Chapter 9
Sq. Ft. Floor Area
Valuatio$107
(commencing with Section 7000) of Division 3 of the Business and Proposal... Cattle) w
that M I. exempt Ihemfrmn and the basis for the alleged exemption. Any vialafion of
APN Number
Occupancy Type
Section 7031.5 by any Applicant for a permit subjects the applicant in a civil penally of
not more than Eve hundred dollars (3500).
❑ I. as owner of the Pomeroy, or my employees with wages u their Sale compensation,
35618071.00
Required Inspections
will do the work and the Someone is not intended m offered fersalc(Sec. 704, Business
and Professions Code: The Contractor'. License law dead not apply m an owner of
e q
property who Indicts or lmprom thereon, and who doessuch work himselfor through his
Ire
own employees, provided that such Improvements ate not intended orooered fat Sale. If.
however, the building or improvement is sold within oro year of compledon. Ne owner
Wilder will haw And burden of proving that lue did nm build or improve for purpoe of
sale.).
❑ 1. AS owner of Ne property, am exclusively contracting with licensed contractors to
consumer the project (Sec. 7(344, Business and Refusions Code:) The Contramob U.
eense Law dew Out apply man A. of pm,ny Saha builds or improves Nemo., and
who contracts for such projects with a contracmr(s) licensed pursuant in the Cotmacor'.
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tcense Law.
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I am exempt under Sec. B k P C for this reason
Owner Data
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WORKER'S COMPENSATION DECLARATION
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1 hereby aBinn under penally of perjury oro of the following dedvnlous:
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1 haw and will maintain •CeniOesm of Consent to self -insure for Worker's Compen-
asomr, as provilled fur by Section 3700 of the Labur Code, for the performasee of the
work far which this Permit is stalled.
0 1 haw and will maintain Worker's Compensation Insurance. as required by Section
3700 of she labor Coe, for the performance of the work for which this permit is isswd.
My Workers Compsomarulnoranceearicrand licynumberam:
GrrJeG P No.: _
CERTIFICATE OF E%EMP. NPROM WORKERS'
\Jf�//
COMPENSATION INSURANCE
(Thuscclian need not be completed if th Permit Is fmowhundm4dollars (SIM)
or ICM)
1 cenify that In the performance of Ne work for which this permit is Want, I shall not
employ any pc(pg in any manner an As at become wbjullo the Worked Compenullor
Law. of calibaf Bi. Dam
App li t- — —
NOTI iO APPLICANThould
.fmTmabng Ns c lm ¢misers. you s
e subject to the Worker's ComPcn4tion provisions of the Labor Code, you must
forthwith comply with such previsions or this Perrot shall kc deemed revoked.
,
CONSTRUCTION LENDING AGENCY
I hereby Affirm that Nem its constraint lending agency for Ne Performance of
the work for which this permit is luued (Sec, 3(191, Civ. C.)
Under', Name
Lender'. Address
I cenify that I haw mad this application AM rote that the above mfommion is
cored. I agree to comply with all city and county ordinances and sum law$ relating m
building con.wetion, and hereby auNunre MPruematiws of this city to enter upon the
ahove-mcntimed property fur inspection PurPoseL
(We) agree to Saw, indemnify and keep humkst the City of Caperton against
liabilities,judgments, costs and expenses which mayor an way attoe against said Cty
in consequence of he Starting of this permit.
APPLICANT UNDERSTANDS AND WIL LY WITH ALL NON -POINT
Issued by: Date
SOUR REGULATION
Re -roofs
Type of Roof
/� J� 12-11`03
Si lure of Appitcanutontractor Date
HAZARDOUS MATERIALS DISCLOSURE
WIII the applicant or future building oceupant am. or hand]. hanNous materal
as deOncd by the Cupenmo Municipal Code. Chapter 9.13, and the Health and Safety
Cale. Second 33313(x)7 /YT 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
WIII the applicant or foods building Occupant use equipment or devices which
I Nr rdow air contaminants as dofirmd by the Bay Arts Air Quality Management
all new materials for inspection.
District?
❑Yes -r1 No
I have rend the Wxa kMS materialsrequimmcnu under Chapmr6.95 of the Califon
ole Heslthh Salmy Code. Suoota 35505,25533 ata1255M. 1 understand thud Ne building
dots not a tremly hew a lenana. Nat it b my reaponsibiliry m notify duo oce.papt of Ne
acquirementswh' h must be met poor m'I�Se.gCC.facQtiflcamnf Gccuparcy.
Signature of Applicant Date
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All roof coverings to be Class "B" or better
agent-- Dam