05070132CITY OF CUPERTINO+`"`
BUILDING DIVISION PERMIT
CONTRACTOR INFORMATION h"
BUIL DING ADDRESS:
NOVO CONSTRUCTION
PERMITNo05070132
0355 N DE ANZA BLVD
R'S NAME:
PERMIT LS9UE DATE
VIDOVICH-CUPERTINO LIMITED
PAR1042 HAMILTON
08/09/2005
E:
SANITARY NO. CONTROL NO.
(650)701-1500
ARCHITECTIENGINEElt
BUILDING PERMIT INFO
BLDG EIFCT PLUMB MECH
LICENSED CONTRACT'OR'S DECLARATION
o
Job Description
I hereby affirm that 1 am limed under provisions of Chapter 9 (Commencing
with Section 7") Of Division 3 of the Business and professions Code,and my license is
in full fora and erre,. -
REVISION ORIG. PMT#05060034
Lt.MaeLic. M
Delc I
-
ARCHITECTS DECLARATION
I understand my plan shall he used as public records
Licensed Professional
OWNER-BUILDER DECLARATION
I Wreby affirm I am exempt from the Contractors Law for the
Any
oro Cade: Any city ar county
on Business and : C
massa. (Section 703
followhich
wet. de or Pair awnam
re construct.
which re nstr t. alter, nt
a Permo.
],
signed suwmcm
for m n Permit e ed
the the applicans for such permit m f I.
also n th,i
its issa also
prior m its censed
Sq. FL Floor Area
Valuation
s
thaWiscing wJ pursuant 10 NCCam.nssanicestmion(Chapter
Sectioothc of Diviouaf
o&)or
(commencing with Section? of Divisions of she Business Cndc]ter
pto.rAny Vi
Nat he u aempt tMrtfmm and Ile bus far de alleged exemption. Any violation or
and
er
OCC ey Type
Section 7051.5 by ay applicans fora permil Mbjeess Ne applicant in a civil penalty, of
not mom Nen Brc hundred dollam (SSW).
❑ I. u awner of Me pmpery, m my employeM W ith wages M thmir Mle compenmition.
Required Inspections
will do the work. and Use structure Is not intended or offered for sale (Sec. 70a4, Budnev
and Professions Code: The Contractors License Law does not .11, w m awn, of
property who builds or imposes thereon, and who does such work himself or through his
own employees. prownicd that such impro emenu are not intended oroffered for mile. If.
howmveq Ne building ar'unpmvcmcnt is sold within one year of complcuon, the owner-
builder will have de W Nen of pmving Most he did not Wild or improve for purpose of
sale.).
❑ 1. ea owner of the property. am exclusively contracting with licensed convectors to
construct the projeet (Sec. 7044, Business and Profusions Cotler) The Conlncwrs Li-
cerm Law does not apply w an Owner Of property who Wilds or Marrows themon, and
who contracts for such projects with a cont acmr(s) licensed pursuant to the Con racsorl
License Law.
❑ 1 um exempt under Sec. . B 6 P C for this.azon
Dat
WORKER'S COMPENSATION DECLARATION
I hereby affirm under penalty of perjury One of the following declarations:
ave and will maintain a Ccnifieac of Consent to self-insure for WorkerSCompen-
. as provided for by Section 37W of the Labor Code. for the perrom amee of the
for which Of, permit is issued. .
arc and will maintain Wurker's Compensation Insurance, az nequi.d by Section
10311,of
he IoW, Code, far the p ffunsm se of the work for which this amtit is issued.
r
mke' Compen aIi nInlusand Policyr mbcr am:r.
('• liry No.: I5�0 y� ^
CERTIFICATEOF(EMPIONFROMWORKERS'
COMPENSATION INSURANCE, �j --D.7—Of
(This xminn need notWcomplamJ if the permit is (arodmddnllars( 100)
or Ices.)
1 certify Nat in Ne performance of the work for which this pemlit u issued, 1 shall not
employ any Pelson in any marmer x as to become subjected the WMIC S Compensation
.
Laws of California. Dam
Applicant
NOTICE TO APPLICANT: If, after making this Certificate of Exemption, you should
become subject w the Worker'I Compensation provisions or the Labor Cade, you mum
Onhwith comply with such provisions or this Permit shall be deemed Cooked.
CONSTRUCTION LENDING AGENCY
onstru inn lending agency for the performartt of
Ihereby that Nem issrn
ichthi
' the work fur which this permit u issued (Sec. W9T, Ci, C)
(See.
Lenders Nam.
,
Lender's Add..
j I ceNfy that I have mad Nis application and some that the shove inf.tmaian is
' corecL I agree to comply with all city and county of inances and sum laws relating to
Wilding conllmction. and hereby authoris, representasircs of Nil city. corer upon the
above-mentioned property for inspection purposes.
(hoc) agree to save, indemnify and keep hi m ic. the City of Cupcninu against
j La "aa,judgments, costs and expenses which may in any way accme against Mid City
in cone nee of the granting of this permit.
( APPLICA UNDERSTANDS AN ILL COMPLY WITH ALL NON-POINT
Issued by: Date
SOURCERE LATIONS.
Re-roofs
Sigrmt App aAumumr Date
AZARDOUS MATERIALS DISCLOSURE
Type of Roof ,
Will the applicant or future building Occupant mom or handle hmaAaus material
efincd by Ne Cupertino Municipa' ode. Chapter 9. 12, and the Health and Safety
Sees.. 25532(ar'
All roofs shall be inspected prior to any roofing material being installed.
❑Yes u
If a roof is installed without first obtaining an inspection, I agree to remove
Will the applicant or rule. Wilding occupant use equipment or dcviaa which
Ihavardous air contaminants az defined by the Bay Area Air Quality Management
all new materials for inspection.
ia?
71 Yes u
I.
Ihavemadthehva (lusmawrialsmqui.mensunderChapmr6.95of&Califon
ca Safety Code, Scemoes 25515,25533 and 25534.1 understand Naz if the Wilding
not cu ly hwc a mount. Nat is h my responsibility m antsy the teC.P.L of the
rements . MUMWmetpri iMaanttonc.rti6.ateara�apmry.
Signature of Applicant Date
All roof coverings to be Class "B" or better -
Owner .
a .oma .rat Dar.