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CITY OF CUPERTINOw+�a�;maaxxTlc.r'isr
BUILDING DIVISION PERMIT
CONTRACTOR INFORMATION
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BUILDING ADDRESS:
PERMIT NO.
DEVCON CONSTRUCTION INC
04050120
Piam :
PERMIT ISSUE DATE
THE PQRT44 AT RANG119 SAN 2Z44
vE:
E)N1690 GIBRA13TAR BR
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SANITARY OL NO.
ARCHITEC (ENGINEER:
BUILDING PERMIT INFO
SLOG ELECT PLUMB MECH
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LICENSED CONTRACTOR'S DECLARATION
Job Description
1 tremble affirm that l am licensed uZ p visions or Chapter 9 (commencing
with Section 7") of Division 3 of the Busincs. Professions Code, and my license is
in full fns dcrcea6 Licg P3
Liavc
HEALTHCARE CENTER (24 UNITS) '
':-21300 SQ FT
dLL' CONra[br
ARCHITECTS D�ELLAjATION
. .
1 undcrnanJ my plana shall W recd e.1�PoMrc rc[mds
Licensed sionsl
OWNER -BUILDER DECLARATION
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1 hereby .(Sero that I em eaempl from Ne Conuacmo License Law for the
hereby
,
following mason. Code: Any city ms county
constr. Beinus and
sae. imvions
which Peron I m any
I.. a prom. sea construct, alar, iapmw,
h Permit a e. sir
amirme t
priormitsissuance,alsorequires the ilio o for suchpermitm Glcasigned suamcm
its
(commis licensed pursuant
Sq. FL Floor Area V I� C
S fP80
of Division Sof Come) r
(commencing ction7 )of Doiouofof a Bummrs;and Professions
Businessmpt
N S 0 0
log
on. AnynnsCedc)ser
dieaion]Ond
al
that he u exempt mcmfrom and Ume buil for IW alleged exemption. Any violation of
that he is
tit go,
Section 7031.5 by any applicant for a permit subjects the applicant to a civil Penalty of
APN Number OccupancyType
YP
not more man fw hundred dollars (55001.
/ng
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❑ 1, u owner of the pmpcny, or my cmploycu with wage u IWir sole cempenmidon,
)/-
- oar.sw
Inspecttons`�
will dodue wals. and are structure is not intended or offered fmrsale(Sam. 7044, Business
and Professions Cade: The Conani License Law dors not apply m an owner of
Required
property who buildsor Marrows thereon, andwho doessuch work himself or through his
own employee, provided that such improvements art hotheaded oroRered for mile. IL
however. the building or improvement is old within ane Your of completion, me owner.
builder will have the burden of proving that W did Out Wild or improve for purpose of
sale.).
❑ I, as owner of the pmperi , am aadusively contracting with licensed contractors to
contract the project (Sec. 7014, Business and Paufmions Code:) The Contractor's Li-
cense law does not apply to an owner of property who Wilds or improves Ramon. and
who comms for such projects with a eortractor(s) licensed pursuant to dr Conwcsors
License rave.
❑ 1 am exempt under Sec. B At P C for this recon
Owner Date
WORKER'S COMPENSATION DECLARATION
1 hereby affirm, under Penalty of perjury one of me fallowing declarations:
have and will maintain aCeniGcate of Consent to self insure for Worker'sCompen-
11 on, as provided for by Section 39W of da labor Cotic, for me performanee of the
Wfor which this permit is issued.
I have and will maintain Worker's Compensation Insurance, as required by Section
of Ne laborCodc, for the performance or the work for which this permit is issued.
My Wmkm's Compensation lnsurance..--c/azrrcr and Policy number am:
nie R.G. Q✓IC .YN<Per No.. KK
CERTIFlCATE OF E%NMON FROI.f KERS'
COMPENSATION INSURA CE
(Thixsection need not he completed if the permit is format hundred dollars (SIM)
at Ices.)
I cenlfv that in the performance of the work for which this permit is issued. I shall net
..Ploy any person in any manners as to become subject to the Workers. Compensation
Laws of California. Date
Applicant
NOTICE TO APPLICANT: If, after making this Ccnificaa of Exemption, you should
Wmme subject in the Worker's Compeuadon provisions or the Labor Code, you mesa
foMwith comply with such provisions or this permit shall W deemed revoked.
CONSTRUCTION LENDING AGENCY
I hereby aRrm that Nem is a convection lending agency for the performance of
IW work for which this permit is issued (Sec. 3M. Civ. C.)
Lenders Name
tender's Address
I cenify that 1 have road this application and some that the above information is
coma. I agree to comply with all city and county ordinances and slate laws rotating to
building construction, and hereby aomada rtp.matives mf Nis city a enter upon Ne
above memiuncd property for inspection purposes.
(We) agree 1. saw, indemnify and hick may in on the City of .gamins against
costs and pewhich they in any way oceans against cid City
inconses.enceo the of this
inconsequenceof the granting or this permit.
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON -POINT
Issued by: Date
SOURCE GULATIONS
`[Fe -roofs
Type of Roof
C —/
gnamrc of AppitcamurContracko Daa
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future building omupantstoro or haodle haa4Nous material
a dcfned by the Cupertino Municipal Code. Chapter 9.12. and the Health and Safely
Code. Section 25512(.)?
[]Y. XNm
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 the applicant or future building Occupant use equipmentor device which
. hararJcus air contaminants u defined by me Bay Area Air Quality Manag.ment
all new materials for inspection.
in?
t]Yu ry{Nti
I have mad the harardn is materials requirements under Chapter 6.95 of the Carlos,
Ma Health & Safety Code, Sections 25505, 25533 and 255)4.1 undersand that if me Wilding
does not curremly have I tenant that it a my responsibility to .061, tM occupant or the
mquireacnexwhich mum xmet prior orimuartceoraccrdrmaamfocmpanry.
Signature of Applicant Date
coy
I roof coverings to be Class "B" or better
ncr or authorimd agent DateAI