08020122 CITY OF CUPERTINO € 787. q
BUILDING DIVISION
PE MIT .
PERMIT NO.
e1nLfl�rD�RFss: 08020122
DE ANZA BLVD HOWARD WRIGHT CONSTRUCTION
NER'S NAME: J PERMIT ISSUE DATE
11 SCS ADVISORS, SEMI SALMI P.0 BOX 3764 02/20/2008
PHONE: (206) 447-7654' SANITARY NO. CONTROL NO.
ARCHITECffENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
am'z LICENSEDCON AC1OWS DECLARATION lob Description
vs, 1 thereby,Rem mar 1 am banned under pmvigtoor of Chapter 9(Commetint
with Section 701111)of Oiviaian 3 of the Business and Profcabm Code,and my ticcnm is COMM'L TI, REST RMDL BUS SPACE
in full forte aroteffect. 6 38
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C;: Dab—Z-?O•n R Congesun
C;:
ARCHITECTS DECLARATION
R< 1 undersand my plans will M used as public reaNa
yo Licensed Professional
OWNER-BUILDER DECLARATION
"M I botchy unne that I em exempt from the Contrawara License Law for the
D O fallowing mourn.(Section 703 1.5.Business and Profeaiot Cab:Any city or aunty
$fii which requires a Permit b connmca alar.Improve.demolW,or repair any suucm e '
_Z'n prior m its issuance.also minim dteappliant forsuch Permit m Ole asigned Moment
sip< that he in licensed pursuam a de provisions,of the Conusubr's Limnos,Law(ChaPleT 9 'Sq.Ft. Floor Area Valuation
(<ommencin{wish Srnian 7040)of OivuionJof de Business and Profeuirm Cab)or 900000
uy that he is camp,therefrom and the basis for the alleged exemption.Any violation of
Sec decu fume man nve hundred dollar(SM on 7051.5 by any applicant for a permit subjects the applicant a civil penalty Of 3 6 9 O l 0 6 4 . Number Occupancy Type.
❑1,as owner Of dote property,or my employees with wages sm their sale compensation,
will do me Wath.ad the sWCWR Is Out intended or rBCRA mralc($K.70,44,Business Required Inspections
and Pnlfeulons Cade:The Canm ores License Law dons,m,apply b an Owner Of q p
property who butlW orimproves threaten,and who doesauch workbimselfor through his
own employees,provided that such improwmeu tie not Intended moffng!!imago If.
however,the building or improvement is sold within one you of ampledon,the owecr-
Wilder will have the WNen of proving that he did not build or improve for purpose of
ale.).
❑1,as Owner of the properly,am exclusively contracting with licensed anteac,oa In
construct the pmjea(Sec.7044,Basin and Ptfe sdom Cale:)The Cdnuacar'a LI-
cete law does not apply an an owner of property who builds or Improve thereon.and, '
who contracts for such projeeo with a conbacmr(s)licensed pursuant to dun Cor m iotas
License law.
❑I ore exempt under See. ,B&P C for this mann
nes Date
WORKER'S COMPENSATION DECLARATION
I hereby,Him under pesalty Of perjury aro Of the following dmlaatiot:
1 have and will m dualo a Ger ifiam orconsent Ir self-lesuu fur Wormer Compen.
.tion,as provided for by Section 37M of the Leber Code,for me perfan ou ce of the
work for which this permit is issued. ,
❑1 have rod will maintain Workers Computation Imsuamce,u requlmd by Section
37(0 of the Labor Code,for the performance of the wart for which thm Permit Is lead.
My Workers Compensation Insurance artier and Policy number are:
Cartier.ZL)IQAC�A NtieS let.`N,Pollcy No.;42.7 1 4��tat-,
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(This seedon need not W completed if me permit Is foram hundred doBus($100)
Or leu)
I certify that in the performaece of the work for which this Permit m merged.I shall not _
employ any person in my manners as an become subject in me Warton'Compensation -'
Laws or California.Dam
Applicant
NOTICE TO APPLICANT:IL after making this CcniBam of Exemption,you mould
become abject to me Workers Compcwtion pmvisiom of the labs Code.you muss
.J O fougwith comply with such proviaint a this permit{hall W lamed revolted.„z,ry CONsmuc10N LENDING AOaNCY
E•'ti (thereby M.mat dart isaectuued.n leMingagemy,for the perfomanceuf
lYi the were for which this Permit Is issued(Sec.3097,Cho.C.) '
Qlambert,Name
z Lenders Address
U O I modify that 1 haw red this application W eruct Nu the above informades m
Lu H coeren.I agree to comply Mm LI city and county ordinances and sum laws relating to
.0 Wilding construction,and hereby authorize rtPn:anutiws Of this city m enter upon the
WaWw-mentioecd propcny for impaction purpose,
(We)agree to sew,indemnify and ImP hwmlea the City Of Cupertino against
y liabilide,judgemms,cros and exporus which may In any way aero a{Jnr said City
U Z in consequence of the{ranting of this perish,
r-i APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT Issued by: Date
SOURCERE�,U ,CATIONS.
_ \I - 2' Re-roofs
Sitinatum of ApplieadCoecactor Dam
HAZARDOUS MATERIALS DISCLOSURE Type of Roof
Will that applicant or future Wilding aapauroro Or handle ha'rardum material
a dented by de Cupertirm Municipal Cade.Chapter 9.13.wW the Health and Safely
.Section 25532(4)? All roofs shall be inspected prior to any roofing material being installed.
❑Yes -S No
Will me applicant or fulum Wilding Occupant tea equlPma,Or dcvlces which If a roof is installed without first obtaining an inspection,I agree to remove
emit hatmnus air cmuminamm as,dented by the Bay Ama Air Quality Matgemcm all new materials for inspection.
Dieu nT \_
Dyes yNu
I have tend the hasdom materials requirements under CMpbrd.95 ofthe Califon
ilia Health&Safety Cade,Seedau 25505,25533 and 25534.1 understood that if me Wilding
Jam not currently have a mvem,that It is my responsibility to nodfy the uccupat of the
requirements which mug he met prior m Women of a Cenincaw0771711-0
f Occupocy. Signature of Applicant Date
2.'2 0'o y All roof coverings to be Class"B”or better
Owner or aurh Bred agent Disc