08060246 CITY OF CUPERTINO
BUILDING DIVISION PERMITkCOAI,TRACTQR IAFFURMATIO,N ..:_
BUILDING ADDRESS: PERMrr NO.
1.0430 S DE ANZA BLVD TBD - TO BE DETERMINED 08060246
fA1C'1IrECT/ENGINEEk.
R'S NAME: PERM"ISSUE DAZE
S MANAGEMENT 07/11/2008
E: SANITARY NO. CONTROL NO.
BURRING PERMIT INFO
BLDG ELECT PLUMB 'MECH
0 0 0 0
3 o 6 LICENSED CONTRACTOR'S DECLARATION WJob Description
-rd w 1 Wrathy affirm I 1 am Hemmed under PraviGts wof Chapter 9(commencing � p
n wi0S«tion7")of0ivwoa3ofWBmimorandProfc.ionsCode.andmylmcmcis REPLACE ONE A/C UNIT ON TOP OF ROOF JJ AIR
-'z u«IIIIur u�merceLtl']y`?GLmi/ 3S '/ 5�'7
�2_ CONDITIONING PD BUS LIC 6/30/2008
nt„p Date ComraMr
7W ARCHRECTS DECLARATION
1 undersand my plain shall le used as public recoNs
�cU
g < Licemfe
ed Prossional
''0:1 OWNER-BUILDER DECLARATION
1 hereby affirm Nat I am m.pt from the Conuacmh Ucen.Law far W
20 following myon.(Section IW 1.5.Bum.and Professions Cade:My city tar county
�29 which mquiros a prmil to cmemom.alNr improve,demnll L,or n:poi,any mnalme
-iy prior m its issuance,rim mquiru Neapplicam for such Permit m file a signed summcnt
that he is limacad pursuant to the pmvisiamofW Cammcmer U..Law(Chapter 9 Sq.Ft. Floor Area Valuation
Yvs-$ (commencing with Suction 7000)ofDivision SofWBusinessland Prof. 12iomCode)., 500
Nat he u exempt Ihemfrom and W basis for the alleged exemption.Any violation of
Section 703"by any applicant fm a pump subjects W applicant m a civil penalty of Number Occupancy Type
not mom Nan fin hundred dollars($5W). 3 6 9 4 0 015 .'
�I,u owner of Ne pmpmy,or my employes with wega y Wv este compen.tion.
and Fr feirk,and Wswerum erotintendedoowde sOutup,],toa.i,Basin.
and Prtywho Cade:The CanuanoYs Liar¢Law dor not apply m an Owner of Required Inspections
.em who .Idaviireprowschurp and.is demsuchwok or offered
his
.employ=.me building
prwapimPs"to wit
am not deniedmo@rod for sawner,
however.Ne bve th L huimprovement tssold he
nat year of. prove for
Wawe of
builder will thew W burtla of proving that he did mat bWld or improv(act purypy of
.mJ.
❑1.as awes a(the property,.eaclusively canuacumg with Boerued Lmnuacma to
mmtnsct W project(See.706,1.Bushey and Peafcsuons Code:)The Cmt.cmrs U.
..law does ool apply to an owner a propeny who builds on Word.Wreon,and.
who contacts for such projects with a conuvcmrt0 licensed pursuant m W Conuactor's
Lice.Law.
am eacmpt unam Sec. .B k P C for the mown
s
Data
WORKERS COMPENSATION DECLARATION
1 hereby"Tim under penalty Olfactory arc of W relieving decieratiom:
❑I tum End will maintain a Crdfimmaf Comm m wtf.imum faworkcescompcn-
.tion,.provided far by Section 3700 of the labor Code.for Ne perPormaace of the
work for which thio permit b icued
t�I have and will maintain Waite's Campem rebut Imuran.,u mquimd by Section
3700of W Labe Code,far W Performance offt work for which this permit us issued.
My Worim's Command n lmmance Leri and Policy num am:
Cartier.-5&A Rd QiL a'F� holiry No.: 2/
CERTIFICATE OF EXEMPTION FROM WORKERSt
COMPENSATION INSURANCE
(Thfsucdan need not becompleed lithe Permit is forom Wummd Corona($101))
or Leas)
1 ari(v Wl in one performs um of lie work far which Nis Permit it heated,l shall no
employ any perwn in any manneren a m become subject to W Workers'Compe be on
Laws of Caiifamia.Dam
Applicant
NOTICE TO APPLICANT:If.after making thus Certificae of Exemption,you should
became subject m the WortcYs Compenaadon provision of the Labor Code,you mean
.,O (arm o Nshall thwith comply with such pmvidou permit all W 4rod
zmed oke
ZM CONSTRUCTION LENDING AGENCY
[-a 1hemby affirm des Nem is a conauuctim Lending agency far W Performance of
W work for which this permit or hued(Sec.3097.Civ.C.)
W�O Undoes Name
.7 z Lender's Address
U O 1 mtiry that 1 have and We application and sue that W above information is
IL correct I agree m comply with all city and county ordinuees and a=laws miming In
O building comuucion,and hereby mmorim ternmenutiws of this city m enter open ft
yshow-mcndoned property ru inspection pmPmes
(We)agree m rave,indemnify and keep bound.W Cry of Cuperino ageimt
fn Imbilima,judgmenu.casts and eapemca which may in any way warm against said City
U Z in comegmm.of the grating of this permit.
APPLICAN'T,UNDERS7ANSS AND WILL COMPLY WITH ALL NON-POINT Issued by: Date �'/1 - O
SOUR TIONS `j���r
Re-roofs
Signature of AppliantConuacmr Ir Data
HAZARDOUS MATERIALS Df§CLQSUlUE Type of Roof
Will W applicum act Futuro building occupant von m handl.harudom note hal
food by W Common Municipal Code,Chapter 9.12 and W Health and Safety
.Section 15532p)?
[D You �Nn All roofs shall be inspected prior to any roofing material being installed.
Will the applicant or future building occupant um equipment or devicm which If a roof is installed without first obtaining an inspection,I agree to remove
mit bvu baa air mo aminants as defined by W Bay Am Air Quality Management all new materials for inspection.
District?
0Y. u
I have re ad W hnudws deka mquimmauunder Chaphr6.95ofWCalifor-
nuH.INhSafctyCad0.S.dons U5W.25533md2553d.lundcrsundthwifW Wilding
door nal emendy have a moan,than it is my responsibility m notify ae accupant of the
myuimmcomw 'hmuct �etpgrm' uwaora Cm ricae.r Occupancy. Signature of Applicant Date
. - /-d
n[rmwthariaed agant oam- All roof coverings to be Class'fj"or better
- - s