03100201 CITY OF CUPEIRTINO
BUILDING DIVISIONPL'RMIT *!CONTRACTOR INEORMAT ION L
BUILDING ADDRESS: PERMIT NCO 310 0 2 0 1
10101 DE ANZA BLVD
OWNER'S NAME: PERMIT LSSUE DATE
•IOULDS 500 FORBES ASSOC. LIC 10/28/2003
JE: SANITARY NO, CONTROL NO.
ARCHITECT/ENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
0 0 0 0
Too
LICENSED CONTRd under
DECLARATION
wq I hereby affirm Net 1 am licensed BJ under and
Professions
ofsCode. 9(commencing Job Description
fZW with Scnion]B(IU)ofDivisipnJoftheBusincasandPmfcssinmCndc.andmyliccnseis �g
±may in full fume and efma. TI- -2 CEILING HT WALLS/1 D DIORAMA 13
3nLicense Class Lic a
,Fn
Dale Curnmeo,
qqARCHIIECT'S DECLARATION MAR 11 r) '1 1 O �OQA
Y
I C I understand my plans shall W used as public rtcaM
rds
JdU
�LLOt' Licensed Professional
3 OWNER-BUILDER DECLARATION • a• 1tl DIN
BUILDING
UI G
a q 1 hereby affirm that 1 am exempt from the Contractor's License Law for the ®
00 fallowing reason.(Section 7101.5.Business and Professions Code:Any nay or county
<m which mquires a limit to mmtruct.idw.impnavc,demolish.or repair any strunum
$2000
pdnrloiuissuance.aLsorequires thcapplieant forsuchilemotu file asignedmounical
ra that he is licensed pursuant to the provisions of the Contractor's Limns Law(Chapter 9 Sq. Ft. Floor Area Valuation
Zr (mm mencing with Section 7001)of Division 3 of the Business and Profession,Code)or
1�$ that he is exempt therefrom and IM buil for the alleged exemption.Any violation of 32636071 . 00
Section 7031.5 by any applicant for a permit subjects Ne applicant to a civil penalty of APN Number Occupancy Type
notmomManmehundreddollars(S500k Pane Y YP
1,ax owner or Ne property,or my employcu with wages u their sole compensation,
will do Ne work,and Ne swcwm is not intended or offered for sale(Sec.70aa,Business
and Professions Code:The Contractor's License Law dues not apply to an owner of Required Inspections
property who builds or improves Hereon,and who does such work himself or through his
own employmes,provided that such improvements arc not intended oroRered for sale.If,
Wwe eq the building or improvement is sold within one yeti of completion.But owacr-
builder will have the burden of proving Nat he did not Wild or improve for purpose of
Cs(Slc .
I,as owner of Ne property.am exclusively con inning with licensed convenors to
tract Ne project(Sec.704L Business end Profcsaions Code:)The Cimmunn rh Li .
cease law dues not apply to an owner of property who Wilds or improves Metocn,and
who contracts for such projects with a contractor(s)licensed pursuant a Be Contractor's
4h�
crop,under Sec. _ ,B&PCfrlhisrt
Dale 0 fl n
ATKIN OEC R TION
hereby affirm under Penalty of perjury on,of Nwing declarations:
will maintain a Certificate of Consent to self-insure fur Worker s Comlcn-
ration,as provided for by Section 37W of Ne labor Cade,for Nc performance of the
work for which this permit is issued.
I have and will maintain Worker's Compensation Insurance,as required by Section
37W of the labor Code,for the performance of Ne work for which this permit is issued.
My Worker's Com pertsulion Insurance carrier and Policy num her art:
Caner, Policy No.:
CERTIFICATE OF EX EM MON FROM WORK ERS'
COMPENSATION INSURANCE
(This scainn raced not W completed if ft I mmut is Word hundred dollars($100)
or lia.)
I certify Nat in the performance of Ne work for which this permit is issued,I shall not
employ any person in any manner set as to become subject to the Workers Compensation
Laws of California.Date
Applicant
NOTICE TO APPLICANT:If,after making this Certificate of Exemption,you should
become suhjen to the Workcr's Compensation provisions of the Tabor Code,you must
�z forthwith comply with such prnvisinnsorthis Permit shall Wdeemed revoked.
L O CONSTRUCTION LENDING AGENCY
I hemffi
hy arm that There is a construction lending agency lm the performance of
]S the work fur which this permit is issued(Sec.3097,Civ.C.)
i1 Linda's Name
z Lender's Address
1 anify that 1 have read this application and some that Ne above informniun is
L f-' commit.1 agree to comply with all city and county ordinances and sure laws relating ro
V building construction.and hereby amhorim mpmscnaaives of this city to enter upon the
UJ above-mcationcd pmpcny for infliction purposes.
(We)agree to save,indemnify and keep harmless the City of Cupertino against
h hall lilies.judgments.costs and expenses which may in any way accrue against said City /}s,
;j,'Z in consequence of the graft ng of this permit / O
'—' APPLIC UNDERSTAND A WILL COMPLY WITH ALL ON-P INT Issued by: Date 1
SOUR^ U ATIO W-- LO
Re-roofs
Sign rc App tF n onf acro D tc
HAZARDOUS MATERIALS DISCLOSURE Type Of ROOF
Will Ne applicant or future building occupant more or handle hmarduus material
as defined by the Cupertino Municipal Code.Chapter 9.12,and the Health and Safety
Code.Semon 25572(x)? f\/
❑Yes °'
All roofs shall be inspected prior to any roofing material being installed.
�J'
WBI the applicant or future building occupant use equipment or devices which -If a roof is installed without first obtaining an inspection, I agree to remove
,haordous air contaminants m defined by the Bay Area Air Quality Management
District? all new materials for inspection.
QYcs Nu
I have read Ne hamrdous materials rquirements under Chapter 6.95 of the Califon
Iia Health&Safely Clyde.Soedum 25505.255]]and 25534.1 understand Nu if the Wilding
does I currently have a tela h a it isvny responsibility br norlyt a'cupant of the
m tri menu whichmum be unuissuancc ora Ccrdfiea¢o 0. panty.
Signature of Applicant Date
or DU.1 All roof coverings to be Class "B"or better