07120061 CITY OF CUPERTINO - Faw ++s�i
BUILDING DIVISION PERMIT CONTI2AGTOItINFORMATI�N
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PERMIT NO.
aulL�IrJp��LEs DE ANZA BLVD H H CONSTRUCTION 07120061
WNER'S NAME: PHNV[ESUE DATE
CURRY HOUSE 148 BRUSSELS ST 02/01/2008
PHONE: SANITARY NO. CONTROL NO.
(415) 922-7726
ARCHITECT/ENGINEER:
BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
0 0 0 0
300 LICENSED CONTRACTOR'S DECLARATION Ib Description
V 1 hereby afRrm dist 1 we licensed under provisions of Chapter 9(commercial, IP
al,
wiNSeaion]pXI)of Divinion3ofthe Buuneuand Pm[ausiwu Cotle,and mylicenuis REVISION, CEILING STRUCTURE, ORIG #07070174 NO
in full roar.and effect t u.
S
Lice nanClea. Lfu.g�� NEW .
3 Dau Contractor
ARCHITECTS DECLARATION PERMIT
Y I untlerstand my plane shall W used an,public acmds
76
5' Licensed professional
OWNER-BUILDER DECLARATION
1 heahy eHinn that 11. exempt form Nro Cxfions rue:Any c Law for the
O o following recon.(Salon IDt l.i Business and Pmfussiou Code:Any city or county
me
Z� Nour mqulma s petmlt to mmmmt plot improve,mermil t,or repair any atmcmn,
—ti priarmiu Lssued pursmagethe thovisiosof fountain permittofile asiLa (ataumem
< IhsshetmeingwdpurmaNuthepmviviouafthe Common's lmetasueveLaw mCodc)r9 Sq.Ft. Floor Area Valuation
'hammcncore with therefrom
and
tof he Division r of the Budrceampt Pr.AWou Catle)or $O
`<— Nat he u 31.5 b dtea(rmli and the bola for the aluLed armtat M Any l pen lm of
aSectionm.. down f ve my red dont ren a permit subjects,the applicant u a civil penalty of A.prvJ Number Occupancy e
nm mom Nan Ow hundred dollen(SSW). 36940002 .'ttL' P YTYP
0 1,u owner of the pmperty.m my employco with wgo a Ibelr wan mmpewdon,
wid enthamshms.mEn-The Cemumer'sU doraw acr rmwle(ply toosd.eueimof Required Inspections
prosNtl PmIGW W Cade The xxx th emen.ed who Law date or apply b N aMMf is q P
own em loye Wlldpmlmpmts chi mn,Ndwho dm act iAwork Amnel(m Wr sal AY
own employees,providedNetamhempawmenu see cot intended araReretl foetalis Ir.
however,the building m .of proving that a did ren yeti or imp.
pn.er the owmr
builder will have W OuNm of proving dist he did not thu1W a improve[m puryow of
wk.).
0 1.a.matter at the pmpeny,.m exclusively...suing veld licensed con awars In
couwn we Mjca(sea.rodq.Bulnexe.ad Pallor 1.Com:)The Cmtmelee.U.
comet law does not apply ea an owner clinometry who builds or impmvo then,and,
who contracts farsmut pmjem with a contrawar(s)because pmatunl to use comm me.
Lice.law,
❑I ods exempt under Sm B k P C ren this recon ..
er Dau
WORKER'S COMPENSATIONDECLARATION -
1 thereby aRimm under pomulty of perjury arc of the following do0aratlou:
❑T have and will for by
eCerdaou of Cauem Conn.
lea iceerform a ce olio-
worn,r pmvimi far mi Section 37W of the labor Com.fm the Performance of the
work for which this permit is issued.
0 1 have.cod will maintain Workcr's Compensation Insurance,u required by Section
3700 of the Labor Code.far the performance of ft work for which this permit ie l2ssmd. '
My Workers Compermad.ban.carrier and Policy mumbo ami
Carrier, �Da7- �K A// Policy No.:
CERTIpi fTE OFE%EMPf10N FROM WORKERS'
COMPENSATION INSURANCE
(Thleeemlon nerd an,he completed If the Permit in[mom hundred dodaw(SI W)
or lean)
1 anify that in the perfomturce of the work far which this peon t Is issued.l"I an,
employ any Karen in any manmrm as in became wbjmt he the Warken'Compensadm
Laws at California.Date
Applicant
NOTICE TO APPLICANT.If,spur making this Ceninote of Exemption,you should
become subject in the Workers Compensation prevision.or the labor Cade,you mats
forthwith comply with such previsiont or this permit shall be deemed mvoked.
z 0CONsmuc ION LENDING AGENCY
F4 1hendy.IDrm that them In.eommucamn funding agency per the performance of
C > the work fm which this Permit Is(word(Sm J 'Civ.G
QLeese Namc
=z Londe:Address
U O I comfy Nn I have read this application and Santa Nu dte above information is
commas 1 agaa an comply with all city and county aNinsnm and suis laws retsting to
building construction.and hereby authaom rtpretmudvet of this city to deur upon the
[i7 above.menuomd property lm Inspection purpowg
py (We)agree to wan,indemnify and keep harmlew the City of Cupertino against
(A U'bilitio, eau,co.uand expenses which may in any way amen against said City
V in eo m of Ne grandng of this permit.
APPLICltNT NDERSTAND AND WILLI COMPLY WITH ALL NON-P01 Issued by: Date
SOUR RE ONS. •/
Re-roofs
Signature,of ApplionUConuacmr It Dam O
HAZARDOUS MA Ars DISCLOSURE Type of Roof
Will tic.ppllant or future Wilding aaopantwore or handle hamdou material
as maned by the Cupemim Municipal Cam.Chapter 9.13.and the Health and Safety
de,smdm 25532(.)+
❑Yo ❑Na All roofs shall be inspected prior to any roofing material being installed.
Will the applicml or future Wilding occupant uta equipment or devices which If a roof is installed without first obtaining an inspection,.I agree to remove
emit haudn
em air conuminmu uftmtl m deby the Bay AAir Quality Management all new materials for inspection.
District?
❑Yo 0 N
ave real thehamad.Woods],aquia moustu der Clupterh.95 of the Cilifon
ria thgt Safety Cade. u25505,ZS5J]atW255le.l undrnuntlthui(dw Wilding
Jena l c ndy hew•teex t t k a my ponsihlloy te nodry de cu n
what men m cot ormlwss wotlCenineaaf Signature of Applicant Date
Ownermeutham<dagent Date' All roof coverings to be Class"B"or better