08040035 CITY OF CUPERTINOn5f
BUILDING DIVISION PERMIT -W-QNTRAGT,9RPERNITT NO.
ORMA.TIO,N; w
BU"5,'g.c�.Rq,'tUPERTINO RD TBD –' TO BE DETERMINED 08040035
1^'S NAME.
PERMIT LSSUEDATE
t.6VIN POON 06/11/2008
PHONE: SANITARY NO. CONTROL NO.
ARCHTfECTIENGINEER: BUILDING PERMR INFO
BLDG ELECT PLUMB MECH
t� C71 0 t�
woo LICENSED CONTRACTOR'S DECLARATION IOb Description
in 1 ncreby affirm that 1 am licensed under Provisions of Chapter 9(commencing Job p
r with Section 7")ofDivisiun3oftheBusnessand ProfnsunsConn.and mylicense is DEMO OF (E) 2 STORY HOUSE WITH BASEMENT
O or a full forte ams effan.
en
v�z Licse Lic.L
clear, IZ K19.4 My- firle
7W7W ARCN Ito use DELLA ATIONd
lumsersunJ my Nallkused da Public recor
-u
pd
Licensed Professional
Oat I am attempt
DECLARATION
<E 1 krehy (Tor that 1 1. exempt from the Cssoms at e:Any
Law for tk
y o O followhich.,.areason.(Section 7031.5. t,alter. and Profession Cade:Any city at county
ectme
3_� which requites a permit ro construct,alter,improve,demolish,m copse my struelurt '
Mar to its issuance,also requites the aPplieamfor such Permit to file a signed statement
rO that he is licensed puaoanuoNCProvisions ofthe Contractor'slJcevcLaw(chapter 9 Sq.Ft. Floor Area Valuation
1-s (ccmencingwh Snsan7")ofDiv onloftkBuinatmiPrafcssianCoda)or $7000
.. Nat M u exempt therefrom and Be baso for me alleged exemption.Any violation of
Sectiun?W IS by arty applicants for a permit subjects the asPliCUL b a civil penally OfNumber Occu arc T
not coma man five hundred dolma(Lasso). 3 2 616 0 3 5 P Y YPe
I,00wner oftk proltsry,mmy moPioyw with wagussNeirsole[anpenotian,
will damevara.andme he ctum a urea License
cls fondle(Sar.to aa,Bos--.•
and Profesvon Cove:The Convenor's Lioante law dans mal apply m an owner of Required Inspections
prolwrtywk nauamimPra.a,maaan.ane wnaaao.aan work nimaelrormmagn ria - .
hou ono.th.n,proWded mat sato improvements are oat in¢msri oraRcredfor ole.lf. ---
Wilderr.the octheau ins of prmntisaald didaoteyear or imrmOfm meownuf
Wilder will hale the busdro of proNnL mal k did rot buitl a improse fm purpose of
0 1,as owner of the property.am exclusively contracting with licensed convectors on
rontracl the Project(See.7W.Business and Professors Calc)The Coatracbfs U. .
cense Law does not apply b an owner of prapany who milds or cancocs thereon.and
who contracts for such projects win a commed r(s)licensed punwnt as the Contractor's
Lacs.taw.
lamaemptmder See ,B$PCfminismoW
Date
WORKER'S COMPENSATION DECLARATION
I hereby+frime anter PnultY of perjury dote of the fallowing declarations:
I have and will miateio•Cutifiate of Co..,to self-owae for worker'sCampcn-
andon,as pmvidrE for by Section STDo of the Labor Code,far the performance of the
wart for which this permit is sound.
1 have arms will maintain Worlmes Compensation Insurance,as required by Semon
37M of the lather Code,(or me Performance olthe week for which this Permit is issued. '
My WarT Com nsauan losso maria and Policy number on
Cartier. y H D Policy No.: 601
RT CATS OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(Tru scctlm=ad not k conplemd if the Permit is future hundred danN(LIW)
or ins.)
1 acetify,that in the pe,farmana of Ubu work for which this formal,u issued.I shall am
employ any Nation in any manor at o Is become subject to the Workers CamPenullm
Laws of California.Data
Applicum
NOTICE TO APPLICANT:IL after making this Certificate of Exemption,You should
become subject to the Worker's ComPenavan Provisions of the Labor Code,you must
.J z fuMwilh comply vim sen prov(vr a"a permit Nall k deemed rooked.
CONMUCTION[.ENDING AGENCY
[-. 1 hereby affirm this Bert it a construction lending agency for the Pcrfommce of
r1, me wort fur which this pennil u issued(Sec.ADT;Civ.C.)
0.n fender's Name -
Z: z Lender's Address
U Q 1 certify that 1 have mad this application and all that the akw information is
[L F cored.l agree to comply with all city and county endurances and sub laws reading to
�U kildin[ronsuucuan,and herebyamnorim mpr.senuvves ofmis city to enter upon the
[21 akve-mendancd property,for inpection pugwes
gL (We)agree to on.indemnify and tap haarleo tk City of CLperlinaatafai42
V) IiahiRds,)udgmcnu,cosuan .r Keenest which may in any way..,...o iginl a id City
U,'� in consequence of the iaanunL of Nu permit ---� -
^' APPLICANT UNDERSTANDS AND WILL`COMPLY WITH ALL NON-POINT Issued by: Date
SOURCE REG UI.ATIONSi� l ( O�
Btgnata pphaaiyc`tr,emr —7� Re-roofs
/ HAZARDOUS MATERIALS DISCLOSURE Type of Roof
Will tau:applicant m fact.building aetle nt atom m handle hardous materii
Rand by Jm Cupeaum Municipal Cade.Chapter 9.12.and the Health and Safety
.Savor 25552(.)?
❑Ya Na All roofs shall be inspected prior to any roofing material being installed.
Will the apprart of future building occuwnt use equlpmml or deicer which If a roof is installed without first obtaining an inspection,I agree to remove -
emit harardou¢air cmumimaa as dcftnN by the Bay Area Air Quality Management all new materials for inspection.
District?
❑Tau
I ham read the WaNew rwcriab mgaimanc usunder Chapter695 of the Califor-
nuHnlmB Safety Cada,ScNaas 25505,25555 sad 2355.tmdefsund muifdc building
does col cmremsy have a mnan4 that it is an lfipmsl"nlity b ratify the aavpant of the
requirements which mtlxmam'rW amcof.Cauliicttear C-Puvy Signature of Applicant Date
-Ounm as aamamcd ager' Date- All roof coverings to be Class'p."or better