08050174 CITY OF CUPERTINOSM, �"'*
BUILDING DIVISION PERMIT CO1�G RAC'I'ORTNFUItMA` 10N
BUILDING ADDRESS: PERMIT NO.
22445 CUPERTINO RD SAMUEL CONSTRUCTION 08050174
R'S NAME: PERMIT ISSUE DATE
SUNNY VIEW LUTHERAN HOME 2141 CAROBWOOD LN 07/18/2008
PHONE: SANITARY NO. CONTROL NO.
(408) 262-2727
ARCHI ECTIENGINEER: BUILDING PERMITINFO
BLDG ELECT PLUMB MECH
3;o LICENSED CONTRACTORS DECLARATION O O O O
U 1 Beeby.Ilion W.1 am lienssi abler provisions of Chapter 9(eammccein6 Job Description
^� with Section70M)af Division 3afdw Business da al/Pmfcssmns�CTcdc.md my]I..is REMOVE WALL AND REMODEL HALLWAY-PAINT. 1HR FIRE
oy mfull fomeandef.L Je.P 7/ Z
Dg? Lk===� �• / SEPARATION WALL.
s, Dau Conhaear
ARCHITECTS DECLARATION
I understand my plans shall W used as public records
e
LLat; Licensed Pmfcssianal
5 OWNER exempt from ft RATION
ZOO I hereby.(rim.that I am mumps Item a r Cssionsrs License law for du
ZOO o !Mowing massa(Section t 7931.5.Business and Improve,
um demolish.or My oily or coan.y
S$ which its iss a permit w,ti st he.alar.im[mrsu ermttor repair any stmrsam
the heor iuiensedp seahe requires therimmuant for suchprmitumnse,Lnedsuument
Nathekliconsed pSeatant 70th)of Invoic 3the cBOi ..d Prselsw(Chapur 9 Sq.Ft.Floor Area Valuation
B (cat he I. awith Section]0 and
of Division3 tof he
Business andon.Any
Code)or ,27000
Nath k esemp o .ppli and the bask for the eats am exception.Any violation of
Section]deuce five
limy rdicamn(apermit suWjecu the applksntm.civil pensity Of Number Occupancy Type
mot team th>o BK bartered.oleo(ssaB). 3 2 61512 4 �� P Y YP
0 Las owmofthe property,ormYmoployces with wa,mas dry sek compensation,
wBldothatwortandthes u umkwtimmwoff edforsak(Sec.TON,Basins
and Professions Code:The Conuu mea License Lew dam an,apply in an Owner of - _ Required Inspections
Property who huildaerrinspovmthereaa and whadoessuch workhimvJforthmagh his
owns employees,provided ousuch impn wmares art and intended orolTeed fmsale.V.
however.the Wilding or Wpmwrnenl Is mid within oro year of completion,ora owner
builder will have the WNcn of proving plat he did not build or imposes for purpose of
sok.).
. ❑L as owner of dx Property,w exclusively conuaeing with licensed conuwrtan as
construe the poyeet(Sec.]Ode,Business and Professions;Cade:)The Canmcurs V.
comae Law dam not apply to an owner of property who Wilds or improves oertan,and
who conuau far ouch pmjecta with a comommr(e licensed pursuant in the COnuamors
Lumen,Law.
wmcmpundersec. ,B&PCfmthismawn
Dau
WORKER'S COMPENSATION DECLARATION
1 hereby afford under peoaltY=f pejur,one of the following declarations:
❑I law and will for by a tion 37 uof Conserv r Corm.far for Workers Compenm
,hoof r provided for by Section 3]000!oc Labor Code.(m dm p:rfamrena of Uw
work for which this permit is issued.
❑1 have W will maintain Wort=rs Compensation Insurance,as mqured by Section
3700 of the Labor Code,far the performarce of the wort for which this permit It issned
My Workers Comp1ens_aWn Insurance carrier end Policy number are -21
ier.
CarrTC-fZ�It C( Policy Na:Z24 0 111 Z 2
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(This section need not c completed ifthe permitis Insane hundred dollars(SIM)
or leu)
I mafv that in the performance of the work for which this permit is issued.l shall rte
c,nploY any Peron in any manner am u u become subject to ora Workers'Compensadem
Laws of California.Dau
Applira i
NOTICE TO APPLICANT:If,after meting this Certificate of Eaempuan,you amid
became subjm u the WOrkcrs Compensation provisions a the Lebo,Cade,you mus
.J O forthwith comply avian such provisions or this permit=hall bo deemed mwked.
E
4
CONSTRUCTION LENDING AGENCYve " I amity affirm that sem it.eoiwncusn kndingagency far the performanceof
Ci > the work for which ole Permit is issued(S«.3091.civ.C.)
6Wi Q Lcndcrs Nene
2 Lenders Address
U O 1 certify oat 1 have read this application and sate that tho above W.U.k
p.E cams 1 agree be comply with all city and county oNlwaas and sou laws rtlaunE u
C) Wilding construction.and herebon. y monrire representatives of this city ta enter upon the
r G aborc-mentioned pmpasY for Inspection purposes
(We)agree to taw,indemnify and keep hamless the City of Cupertino against
r�—rZ in
gence of mcosuand mycnseawhich coq in erryway amue againusaid City
U Z A PLICAcnco of drt granting of this ne WILL
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NONPOINTIssued by: Date / �(
SOURCE REGUtvQT10NS. .
-21-1$��� Re-roofs
Signuure ofAppllea. onucor Date
ARDOUSMATg=UP EU=oMndIDISCLOSURE Type of Roof
Will the Cupertnofuture Wadinge.Chapter
havNoamaterial
❑Sectio err Cupertino Municipal Code.Chaper 9.12.and the Heals and Safety
F semen 25532(.)]
❑Yon AN. All roofs shall be inspected prior to any roofing material being installed.
Will the applicant Or future Wilding occupant aro equipment or denim which If a roof is installed without first obtaining an inspection,I agree to remove
cank rtt vMm air canumimnta a defined by the Bay Area Air Quality ManagementDisurall new materials for inspection.
GYes A<o
te
1 haw al the haN a =es materials mquimmenu under Chapter&95 ofdte Califon.
Out Health&SafeYCode,Smano 23305.23533 and 25534.1 understand oat ifoe Wilding
does rat cumody,have a uvea.than,it Is my sapsmibility m scary the .of the
rt pthers ns whic mus W met pia,u issuance of•CeniBcau o Occu m
.N -- 7 f$ Signature of Applicant Date
Owner authave cm p,u All roof coverings to be Class';W'or better
C