05060100 CITY OF CUPERTINO •A,y4 rr'xd vr'g':a, " `'' ,x„-
BUILDING DIVISION PERMIT CONTRACTOR INFORMATIQN
M
BUILDINGADDRESS: ASSOCIATED CONTRACTORS CORERMITND05060100
ER'S NAME: PERMIT MUE DATE
TREND MICRO
PHONE: SANITARY NO. CONTROL NO,
(408) 376-4000
ARCHITECT(ENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
0 0 0 0
�Op LICENSED CONTRACTOR'S DECLARATION , Job Description
I beach,aRrm Nn 1 am licensed under provisions of Chapter 9(occommemil
with Section 7”)of Division 3.f the Business and professions Code,and my license is
or kifull force and effect.
a«nae Cl a ica 0 , 7 REVISION--NEW SECURITY DOOR Q 3RD FL
�-o Date_ Contractor NO NEW PERMIT ISSUED/ORIG. #05020126
ARCHITECTS DECLARATION C rJ QUG JO
z� 1 understand my plans shall W used u puM1lic accnrJs
JyU
C H Liccnud PmRssional
3 OWNER-BUILDER DECLARATION
<y 1 hereby affirm that I am exempt firm the Ci mssnors License Law for the
O O following mason.(Section 7031.5.Business and Professions Code:Any city or county -
KQ 9. which mquims a want in construct.alter,improve.dcmoRsh,or mpair any suunum
prior to its issuance.also aequims the applicant for such permit to rile a signed statement
EiG that he is licensed pursuant toOcprevisions ofOnContractor's License Law(Chapter 9 Sq.Ft. Floor Area Valuation 60
rot- (commencing with section 7")of Division 3 of the Business and Professions Code)or '7
i $ that he is exempt therefrom and the Wais for the alleged exemption.Any violation of
Section 7031.5 by vry applicant for a permit subjects the applicant m a civil penalty of APN Number Occupancy Type
not mom Nan rive hundred dollar(55003.
❑1.asawtmrofoieproperty,army cmployces with wages astheirsolecampernmon, 32634071 ' 00
will Prthework_andtheswnumunotintended mawd for oak(Sec.n th,Business
and Professions cane:The Conheemrc License Law does tort apply lf an nwmr is Required Inspections
ownpholinnywho s,praorimpmvu thimprve who dmisucuoide or offered
his
own employees,0, iprovidedthat such venimpmsamentsora not inrentlrmmoperon thesale.IL
however.Ne Wilding or improvement is sold within one Sen ofimpro a for the ower-
builder will have Nc WNen of Proving Nn he did not Wim or improv for purpose of
canal. i
❑1,as Owner of the pmpeny,am exclusively contracting with licensed immuctors m
conswn thees not (sec.70x4Businessand Propositions Cade:)The Cs themon, std \
Li-
come,law dors not apply a an owner of property who Wilda or improves Neman,and
whence Law.for such projects with acontraaor(s)licensed pursuam total Contractors (� \
LlGtnm Law. v `
❑l oro exempt under see. .B&PC for this mason
Data
WORKER'S COMPENSATION DECLARATION
1 hereby aRrm under penalty of perjury at¢Of the following declanlions:
❑1 have and will maintain a Certificate of Consent to self-insure for Wmker's Campion
smion,as provided for by Section 3700 of the tabor Code,far the performance of the
work for which Nis permit is issued.
0 1 have and will maintain Workers Compensation Insurance,as acquired by Section
3700 of the labor Cade.for the performance of the work for which this permit is issued.
My Workers Compensation lot...prier and Policy number am: ��as
Cartier:UVtb o0wo'lV2, P,"..: NU1040a$
HW
_CERTIFICATE OF EXEMPTION MOM WORKERS'
ll COMPENSATION INSURANCE
This section recd not W comptned if Ile permit is foranc hundred dollars($100)
or less.
1 cenify that in the performance of the work for which this permit is issued.1 shall not
employ any person in any manner to as to Wcomh subject o the Workers Compensation
Laws of California.Data
Applicant
NOTICE TO APPLICANT:If,after making this Ccnificam of Exemption,you should
become object to the Worker's Compenution provisions of the lahnr Calc,you ince
.J O fOMwst
ith comply with such provisions or this permit all be do<mcd revoked.
z" CONSTRUCTION LENDING AGENCY
l hereby afrirn Nat Vert is a construction lending agency for the Mrfor^anm of
gL' ? tW work fur which Nis permit Is issued(See.3097.Ci,C.)
A Under's Name
= z Lender's Address
U O 1 cenify that 1 have mad this application and sure that the above information is
Iy Goren.1 agree to comply with all city and county ordinances and stare laws miming m
OU building construction,and hereby authoim mmesemativrs of this city to cater upon the
above-mentioned property for inowction purposes
(~ gy (We)agree to save,indemnify and keep harmless the City of Cupertino against
rn liabilitiu,judgmcnts.<uts and expenses which may in any way accmc against said City
UZ in eonaagmnce of the granting of this Permit.
^ APPLICANT UNDERSTAN COMPLY WITH ALL NON-POINT Issued by: Date
SOURCE REG
64
rp //5 OS Re-roofs
Signature ofA man onus am
HAZARD_ s MATERIALS DISCLOSURE Type of Roof
Will theapplicanttar onto WilJingmcupantsmrc or handlehe uusmaterial
as de(med by the Cupertino Municipal Code,Chapter 9.12,and the Health and Safety
k.Section 23532(a)?
❑Yu All roofs shall be inspected prior to any roofing material being installed.
�Nu
Will Nee applicant or future building occupant use a tai If a roof is installed without first obtaining an inspection,I agree to remove
PP B P a it Qu Or which g
emit District? nus air cmtaminants u JCEncJ by the Bay Arca Air Quality Management all new materials for inspection.
District?
❑Yer IZitvo
1 have read the Waard us materials requirements under chapter 6.95 of On Cater-
ria Health&Safety Code,Sections 25505,25533 and 25534.1 understand in.if On Wilding
duo nm cure 0y have x¢91 mit is my responsibility to notify the Occupant of the
maimsun r ancehraCent rr asan Signature of Applicant Date
OF
Owner or authonyed g t Date All roof coverings to be Class B"or better