04040126 CITY OF CUPERTINO
BUILDING DIVISION PERMITCONtRAC�TOR�INFORMATION
BUILDING ADDRESS: T & N CONSTRUCTION PERMITN004 04 0 12 6
10151 S DE ANZA BLVD
OWNER'S NAME: PERMITLSSUEDATE
Ighk ELDORADO DRY CLEANER 815 CALERO AVE 06/10/2004
E: SANITARY NO. CONTROL NO.
(408) 712-2168
ARCHITECCIENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
0 0 0 0
400 LICENSED CONTRACTOR'S DECLARATION Job Description
mC 1 bcoby affirm tlut I am licensed under provisions of Chapter 9(commencing
iW with Section 700l)of Division crux Business real Pofcssions Code.and my license is
in toll Tame arra err«t. TI--DRY CLEARNER
jtj License ClmaLic.If .
zinc Dam C«tr«tar CONTRACTOR: T & N CONSTRU ' ti /28/ 4)
ARCHITECTS DECLARATION ti L��
1 understand my plans shall W used as public mcards
;Q� Licensed Professional AUG �oOry
i�ion OWNER-BUILDER DECLARATION Y
I hereby al'Gnn that 1 ma exempt from the ConlructoYs License Law for the
O o following mason.(Sccuun 71n 1.5.Busmass and Prokssimu Cwt:Any city as county
K,ea which requires a permit m crammer,alter,impreve,demolish.ar repair any sweom R1 Igo rsuao^
prior in its issuance,also requires the applicant for such permit to rile a signed statementr>
5,a that he is licensed pursuant the previsions of the Contractor's License law(Chapter 9 Sq. F[. Floor Area
yIaQQQ
VAltoQFttre
C (commencing with section 7000)of Division J of the Business and Professions Code)or
that W is eanmpt thcmfom and the bass for the Jlcgcd exemption.My violation of
Section 7071.5 by any applicant for a permit surplus the applicant to a Mil penalty of APN Number Occupancy Type
not ream than nuc hundred dollars(s500). 35910015 . 00
❑1.as owner of the pmpeny,or my employees with wages al their sole compensstion,
will do the wort and she 6tromum isnot intended or Offered for set.(Sec.7044,Business
and Professoris Code:The Contractors Liame law it.Out apply in an owner of Required Inspections
progeny who builds or improve themon,and who does such work himself or through his
Own employees,pravided that such improsomenm arc not intended or offered forsale.If,
however,the building of improvement is sold within one year of completion.be owner-
builder will have IW burden of moving thu W did not Wild ar improw for purpose of
sok.).
❑I,as owner of the pmpeny.em exclusively contracting with licensed contractors to
consumer the project(Sec.7064,Business and Professions Cade:)The Convector's Li
cc=Law does not apply in an owner of progeny who Wilds or improws Whion,and
who convects far ouch projects witha contractors)licensed pursuant w the Cam actors
License law.
Elame rept under See. B&P C for this reason
Dam
WO KER'S CMIPENSATION DECLARATION
coby affirm under Penalty of Perjury One of the following declarations:
have and will maintain aCcnific4¢of Consent selGnuymrtor WorkcrsCumpcn-
Sadao,as provided for by Section 37M of the labor Coda, the performmce of the
work for which this Permit is issued. ,
❑I have and will maintain Workers Compensation Insurame,as required by Section
37W of the labor Code,for the performance of the work for which this permit is issued.
My Wmwer Compensation Insurance carrier and Policy number arc:
Crericn Policy No.:
CERTIFICATE OF EKEM MON MOM WORKERS'
COMPENSATION INSURANCE
Cfnssection recd not W completed if the permit is for one hundred dollars(SIOI)
or less.)
1 certify Nat in the performance of IW work for which this permit is issued.I shall not y
employ any person in any manner m as m WCame Subject o the Workeri Compem don
Lawa of California.Doc
Applicant
NOTICE TO APPLICANT:If,after making this CcnifaiRc of Eacreption.you should
become subj«t to the Worker's Compensation provisions of the Labor Csale.you most
.J O foMwidi comply with such provisions or Nis permit shall W deemed mvnkcd.
Z " CONSTRUCTION LENDING AGENCY
I hereby aRrm that Nem is come«tion lending agency for the perfurrom.of
C tW work for which his Permit is issued(Sec.3D97,Civ.C.)
ts1 Undoes Name
Lender's Address
JZ
U 0 1 certify that I have read this application and stem that the above infia.m.t is
connect.I agree to comply with all city and county ordinances and suk laws relating in
pU Wilding construction,and hereby authoria represenmims of this ity to enter upon be
W above-mentioned property for inspection purposes.
Ff+ a (We)agree to save,indemnify and tact,harmless the City of Cupertino against
h liabilities,judgment.cost andeapenses which may in any way accme against said City /
U in consequence of the granting of this Permit,
^ APPECAL UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT Issued by: Date
SOU EREGULATIO _ / -_1t—�
Re-roofs
Si sof Ap icanUC ter Date
HAZARDOUS MATERIALS DISCLOSURE Type of Roof
Will the
apPlicam or future Willing occupant atom or handle hazardous mammal
m def Teti by the Cupertino Municipal Code,Chapter 9.12.and the Health and Safety
oda,Section 25532(a)7 All roofs shall be inspected prior to any roofing material being installed.
❑Yrs VNO
Will a a Bram or mom building t sae e t or devices worm If a roof is installed without first obtaining an inspection,I agree to remove
rap s«cupan yuipmcn
t hazardous air contaminants as defined by the Bay Area Air Quality Management all new materials for inspection.
rsvicR
Yn
1 have mad the hvaNrms materials requirement under Chapter6.95 of the Califor
Tia Hcal &S CL Sections 25515.25533 and 25534.1 understand that i(IW Wilding
does n currently hove a tenant.N tit is my resibilt y to noufy tW occupant of the
reqs' cats which mu.Wm at He,On of acenincateofOccuuncy. Signature of Applicant Date
owner ar mihmae again l-. 6 ^ f Data All roof coverings to be Class"B"or better