08060140 CITY OF CUPERTINO
BUILDING DIVISION PERMIT CeONTRACTORI.N'F'URMATIO .
PERMIT NO.
Bu1LgI�cD�eEs�: DE ANZA BLVD TBD — TO BE DETERMINED 08060140
NER'S NAME: PERMIT ISSUE DATE
CIVIC PARK CUPERTINO LLC 06/23/2008
PHONE:
SANITARY NO. CONTROL NO,
ARCNTfECT/ENGiNEER:
BUILDING PERMIT INFO
BLDG ELECT' PLUMB MECH
u p p LICENSED CONTRACTOR'S DECLARATION
1 Wreby alfinn tear I not liarued under pmvitions of Chapter 9(commencing Job Description
dE with section 7")ofDivision 3 afore Business and professions
GCode.and my license is I ILLMN'ID WLLMNTD SIGN& 1 ILLMNTD BLADE SIGN
cts Licenlmfome(nderteet'<
n=� Dam ARCHContractor
ITECTS DEC
kC
U 1 aderwnd my plass shall be used pe public
l`lt; Licensed Pmfcssional
OWNER-BUILDER DECLARATION
I I berth'alarm that 1 1. emmpt form the Contractors License law,17w the
O o following reamer.(Sadao]011.5.Business and improve.
de professions code:Any city or county
$ which da cq a permit hc cit.dxc ..Healter.improve,demolish,m e I airsig ed ny ewetum
riwmitscensed ealw requino dovicios for Inch Permit mStruse LnWmammem
FFo quahee cinwitPersonal
ection tot 1of Division afore the
hireslaw(Chapin9 Sq.F[.Floor Area Valuation
that
gal Salon]BOB)of Diwfor the
al BuonwmtProfessions Code)of $6000
e5$ da ha r 31.5 b taemfrom and the aper far be alleged exemption.Any violation of
de,don]831.5 five
airy applicant(w a permit subjects the applicmt 10.avil penalty.( Number Occupancy Type
not mate dm ties huMred d.11an(S500A 36940002 . P Y YP
❑1,as owner of the property,or my employees wild wagon as their role compensation,
will do do wort and the structure is not inmrWed ar offered for tam(Sec.7041,Busircss
and Pmfetsiam code The caalracmfa L.uads Law d.a ant appy ed so awwr of Required Inspections
pmpenywho Guildswimprosesdeseon,andwhodocssohwmkhimx fwdmughbu
awn employnon,provided shat such improvements are nat Immnded woRemd forsam.If.
however.Ne Wilding m improvement r mid within one year o(completion.the owed.
Wilder sill have dm busdeo of pmving that he did not Wim or improve for purpose of
sale.).
❑1,u owner of the property,am exclusively conmaning with licensed eonoaemes m
cwutrun the project(Sec.7044.Business and Professi.va Cade:)The ComusctoYs U.
caw law does not apply to an owner of property who Wilds or improves demon,and
who contnets for such projects with a con.acter(s)licensed pursuant to tW Contractor's
L@ew law.
❑IamonemptunderSee ,B&PCfwdsmsson
iter Dam
WORKERS COMPENSATION DECLARATION
1 hereby aRm under penalty of perjury one of the following declarations:
1 ham ono will maintain eCutiOam ofConsent Code.
sum fes Workers Camped
swoon, r Provided fes mi Section 3]00 of de lobes Code.fes qua performance of tic
work for which Nr permit is issued.
C)1 have and will maintain Worlmes Compewtion IosWma,as required by Section
3700.17 the LnWr Code.for the performance of the work for which this permit is issued. '
My Workers Compensation how.carrier end Policy number pee:
Cwtur. � .r�Lll//7 Polity Na.:[L(, 6;6 -3
CERTIFICATE OF E)fEMP ION FROM WORKERS
COMPENSATION INSURANCE
G`hb section need not W completed if the permit is foronc hundred dollars($IM)
or mss,)
I certify dont in do perferma cc of the work for which this Permit r hand,l shall not
employ..'person may madman as to become subject to de Workers,Compewtion
Laws of California.Data
Applicant
NOTICE TO APPLICANT:If.after making this Cedifram of Eaemp ion,you should
become abject he the Workers Compewdon provisions of the labs Code,you mw
.J z forthwith comply with such providans or dr permit shall W deemdi revoked,
z O CONS'RUCf10N LENDING AGENCY
1 hereby affirm quit them it.consuuctinn lendin a for dm
g gray performance of
Bwort for wofur which this permit Is istuW 091
(Sa.7 ,Civ.C.) _
e.Uj Q Lenders Name
Address z Lenders Addr
U O I certify that 1 have read this application and sum that the aWve information u
II. correct.I agree In comply wish all city and cowry oNina n-s aha sum laws relating In
.5 Wilding conduction,and hereby Inhumae«pmse.uives of this city to enter upon the
above-mentioned Property for inspection purpws-
F 1 (We)agree m save,indemnify and lacp hand.the City of Cupertino&gems,
Ter liabilities,judgments,costs and expended which may in any way accrue Maim,said City
C)z APPLICANTeor UNDthe
granting
STANDS AND ILL COMPLY WITH ALL NON-POINT Issued by: Date 2 —7 t-4,
SOURCE R
�P y Re-roofs j-
$ignetumofAp i Imcrar Dam
c HAZARDOUS MATERIALS DISCLOSURE Type of Roof
Will deapphmtorfuturebWldingaaupmtammwhandlehror owmatcfial
as darned by she Cupertino Municipal Code icipal CoChapter 1,11,and lde Heald and Eatery
or, ❑Tcyen No.2sssz(a)] !t5 All roofs shall be inspected prior to any roofing material being installed.
Will the applicant or future building occupant use equipment or dcvicas which If a roof is installed without first obtaining an inspection,I agree to remove
emit hmaNnm air conu miens a dcfiad by the Bay Area Air Quality Ma harmer all new materials for inspection.
District? P
❑Yes 4!.
1 have mal de hmaNwu mamdalsmquimmcw undo ChaPrer Q95ofthe Wi(w
err Health&Safely Code SaWns 25505.]5533 and 25534.1 undctsund lairtie Wilding
does not currently have a moans that it is my mndshad ility to mdfy the occupmt of.do
require c met FfiorWissuance of a Cenlrmau,ort]ocupanq' � Signature of Applicant Date
zs �
ow.erw, se see D,m' All roof coverings to be Class'A'or better