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CITY OF CUPERTINO
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BUILDING DIVISION PERMIT
='CONTRACT,0ZINFORMATION
BUILDING ADDRESS:
DEVCON CONSTRUCTION INC
PERMIT NOD5080116
'NER'S NAME:
PERMIT ISSUE DATE
THE FORUM RANCHO SAN ANTON
0690 GIBRALTAR DR
09/08/2005
NE:
SANITARY NO. CONTROL NO.
(408)942-8200
ARCHITEC rENGINEER:
BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
LICENSED CONTRACTOR'S DECLARATION
o
Job Description
I hereby affirm that I am licensed under previsions of Chapter 9 (commencing
with Suction 70M) of Division J of Ne Business and Professions Code, and my license is
imfull force and erket
REVISION-CHG OCCUP GRP FROM R.2.2 TO R.2.1
Lkenx Ctau Lic.p JS`(IG3
Dam —Contra,
NO NEW PERMIT ISSUED/ ORIG. #04050120
ARCHIECT'S DECLARATION
I undcislaod my plans shall he used as public memda
Licensed P.N iunal
OWNER -BUILDER DECLARATION
1 herthy alarm that 1 am exempt form the Contractor's License Law for the
following mason. (Section 703 1.5, Business and Prefessions Code: Any city or county
which requires a Penni) to ennsrue, alter, improve. demolish, or repair any urucwm
prior to its Issuance, also mqulms lice applicant for such permit to rile a Signed statement
Ft. Floor Area
Valuation
that he is licensed pursuant to the provisions of Me Cmura:tm'x License Law (Charter 9
Sq.
(commencing with Section 7000) of Division 3 of Mr Business and Professions Code) or
$103
Mat he is exempt tbnef and and the boxes for Me alleged exemption. Any violation of
APN Number
Occupancy Type
Section 7031.5 by airy applicant fm a permit imitates site applicant o a civil penalty of
not more Nan five hundred dollan (S500).
Q 1, u owner of the pmperty, or my employees with wages as their sole compensation,
Required Inspections
will do Ne work, and de slrucma is not intended or offend for sale (Sec. 70a 1. Busineu
and Pmfessimu Code: The Comtacmre manse law dors not apply in an ..or of
property who builds or improves Merron, and who Cas auch work himself or through his
awn employees, provided Thal such improvements are not intanded in offered forule. If.
however, Me building or impmwmem is sold within one year of completion, Me owner-
/
builder will haw Me burden of proving that k did not Wild or improve for purpose of
\
sale.).
Q h as owner or Me prolan, am exclusively contracting with licensed contractors to
COMOUa the project (Sec. 7064, Business and Professions Cade:) The Contracmr's Li
tens, law does not apply in an owner of property who Wilds or improv Memon, and .
who conrazss for such projects with a contnctor(s) licensed pursuant o the Coormactor's
License law.
Q 1 am exempt under Sec. . B & P C for Mis mason
.
Dale
WORKER'S COMPENSATION DECLARATION
I hereby affirm under penalty of perjury one of Me following declarations:
I hate and will maintain a Certificate of consent to self-inmm for Worker's Compere
cation, as provided for by Section 37M of Me Labor Code, for Me performance of Me
work for which this permit is Issued.Q
1 have and will maintain Workch Compensation Insurance, as required by Section
311 of Me laWr Cade. for Me performance of Ik work for which this permit is noted.
My Worker's�Caxmrpens non Unna anis and Policy number are: t'
Carrier. 6G f"''°`� Pok o.: L1C 29 7 9(i 40 O
CERTI IC F EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(Thu inion need not k campleted if the permit is fm one hundred dollars (SIM)
M lions.)
1 ccrdfv the in the performance of Me work for which this Permit is issued. 1 shall our
employ any person in any manner in as, to Wcome subject to Me Warkeri Compensation
Laws or California. Dam
Applicant
NOTICE TO APPLICANT: If. after making Mis Cenifiam of Exemption, you should
Woome subject to Me Worker's Compensation provisions of the laWr Code, you mum
foMwiM comply with such proviaiou or this Permit shall W decided rewked.
CONSTRUCTION LENDING AGENCY
1 hochre that there is a construction lending agency for Me performance of
which this permit is iuued (Sec. 3097, Civ. C.)
Me work furor which
Le
Lender's Name
,
hendeis Address
j I certify that 1 have read this application and some Mel the aWw information or
' corrcm 1 agree to comply with sit city and county onlinsnecs and some laws relating lr
building conswction, and hereby authorim reprcxnmives of this city to enter upon the
I above-mentioned proPeny for inspection purposes. ,
(We) agree to save, indemnify and keep harmless the City of Cupenino against
i liabilities, judgments, cost it ..,.a which may in any way secret agamst said City
in consequence of Me granting of this Permit.
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON -POINT
T
Issued by: Date—
SOURCE REGULA NS.
e�
Re -roofs
Type of Roof
Signature of AppiltamMorakarefor Date '
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or boom Wilding Occupant stem or handle hazardous malarial
ss dcflncd by Me Cupertino Munlclpal Code, Chafer 9.12. and Me Heads and Safety
. section 25532(a)'!
QYcs XNo
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 equipment or deltas which
it hazardous air contaminants as dcGned by the Bay Ama Air Quality Management
all new materials for inspection.
isuin9
�Nu
Q Yes
1 have mad Me bvardous materials requirements under Chapter 6.95 of the Carfon
nia Hcalth&Safety CUM.Sm OM255U5.25533wd25534.1unkm=dthmifNc Wilding
docs not cunemly have a lenano Mat it is my mapmnsibility m notify the recurrent Of Me
requirements which mum WMet Prior missuancc oft ccnificae Of «.panXy.
Signature of Applicant Date
All roof coverings to be Class "B" or better
'
Owncrorauthod'rcO agent Date