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CITY OF CUPERTINO
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BUILDING DIVISION PERMIT
CONTRACg '0WjNF0RMATION &i4�,
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BUILDING ADDRESS:
PERMIT NO.O 5 0 6 0 2 0 0
10
OWNER'S NAME:
PERMIT ISSUE DATE
SKIN & NAIL AFFAIR
08/26/2005
E:
SANITARY NO. CONTROL NO.
ARCHm!CT/ENGINEER:
BUILDING PERMIT INFO
BLDGO ELECT PLUMB MECH
.
O
LICENSED CONTRACTOR'S DECLARATION
Job Description
lrm n 1 sic licensed under postal.. of Chapter 9 (mrnAmming
I hereby .111.N
with Section TOM) of Division 3 of the Business and ProfessionsCode,aM my liceve is
In lull to-
ueansec Lm.Y
Dau — Contrxtpr
TI -NEW WALL/ELECT/CEILING DRYWALL
PLUMBING/DUCT WORK/
A CHITECPS DECLARATIO
CONTRACTOR: COA CONSTRUCTION (#01000012969)
I on resin my p Wu shall he used es public records
.
Licensed Professional
OWNER -BUILDER DECLARATION
I hereby affirm that 1 am exempt from the Connors License Law for the
following reason. (Section 70313, Business and Professions Code: Any city or county
which requires a permit An comment. alter, improve, demolish, or repair any Rmcum
prior to its issuance, also requires the applicant for such permit in Ole asigned statement
the, M isImnsed pursuant m the provisions of the Contractors Liaom law(Cllepur 9
Sq. Ft. Floor Area
Valuation
(commencing with Section 7M) of Division 3 of the Buster o end Profession Code) or
$63000
that ha is exempt therefrom and see bugs for the alleged exemption. Any violWon of
APN Number Occupancy e
P yTyp
Section 7031.5 by any applicent for a permit subjects the applicant to a civil Penalty of
on,mom than Ow hundred dolWs($50y,
❑ I,uaww of the pmpu,y, err my employes with weetudeh pie cmnpenutlon,
willdatheworkandue snclumi natinmM dorammdforedo(SM.701q Business
Required Inspections
and Professions Cade: 7Le Coes U. Law des cot apply lo an owner of
pmpeny w ho builds cr improve thnmon, end w ho dos inch wick hi mul f err thm W h hi.
awn emplayes, provided Nat swh impmvemenu K Iwtinmadad mommd fault IL
however, the building or Improvement is mid within ons yens of compledm. The ownm-
builder will have use burden of proving that he did not Wild or Improve for purpose of
ole.).
/
❑ 1, as owner of the property, am exclusively contracting with licensed centrmmn a
construct the project (Sec. 7044. Business and Profession Cade,) The Contractor's Li-
«nse law dose not apply in an owner of property who Wilds or improves thereon. and
who contracts for such projects with a conumur(s) licensed parmant w me Contractors
License Law.
❑ 1 am exempt under Sac. . B & P C for this mason
Owner Data
WORKER'S L`OMPENSATTON DECLARATION
LI hemby efflrm under Penalty of perjury We of the following hclamtiam:
LI
and will mainuin a CeWBcate of Consent to self -douse for WorkebCamped.
'a". u provided far by Section 3700 of the labor Code. fm the performance of the
-
work for which this permit is issued.
❑ 1 have and will maintain Workers Compensation Insurance, u required by Section
3700 of the labor Cade, for the performance of the were for which this Permit is issued,
My WorkersC IRT�/or/lon ins varierand Policy number [
Grtler. V�� Policy NL-1-
CERTIFl ATE OF EKE017011 FROM WORKERS'
COMPENSATION INSURANCE
(Thu secdon now rest M1 completed time permit Is foroa hundred dollars (3100)
m loss.)
1 certify that in the performance of the work for which this Permit Is tuuad. I shall nm
employ anypcmon In any mmnerm u w become subject to ted Workers' Compensation
law.of California. Dam
Applicator
NOTICE TO APPLICANT: If, after making this Cenibam of Exemption. you should
become subject At the Worker's Comp mea dan provisions of sec labor Cade, you most
forthwith comply with such provisions m tris permit shell ha deemed overused,
CONSTRUCTION LENDING AGENCY
I hereby affirm that Nem Is a mnswuctinn lending agency far the performance of
the work for which this permit ts issued (Sec. 3097, Civ. C.)
Lender's Name
leml Address
1 certify that I haw read this application sad sum that see above information is
`
comm. l agme in comply with all city sed county ordinances and sum laws retailing to
building cat muction, and hareby authorize represenutives of this city w enter upon the
.hove-menuomd property fm inspection purposes.
(Wel .gree w sees, indemnify and kap harmless the City of Cupertino against
liabilities, judgments. cam and expenses which may in my way seems against said City
in ealleequmme of she gaming of this Permit.
APPLICAffrjor'' UNDERSTANDS AND WILL COMPLY WITH Ay. NON -POINT
Issued by: Date
SOURCEjE¢Jje ?7 �•t/ Q �/U
/ f� �LI U /�(f S
Re -roofs
Type of Roof _
Signuu of�ApplianVCol1��raacc au
HAZMfD S MATERIALS Onowan UR
Willy applicant m funds building now w handle heealth
amamrisi
t
u de0ned by see Cupenim Municipal Code, Gaper 9.17, and that Health and Safety
e. Chaps
Cade, Section 35532(¢)7
❑Yes 191..
All roofs shall be inspected prior to any roofing material being installed.
If a roof is installed without first obtaining an inspection, I agree to remove
1Will the applicant or future building aaupent use equipment or devices which
haumnu ail conuminanu u dcOncd by the Say Are Air Quality Management
all new materials for inspection.
9V C17 .�
6Ny.
❑Yes
I he. mad the h.M. mmrialseewmamenu under Chapmr&95 ANN, Califor-
nu He Ith& SafetyCode, Sadons25305,25533 aod2553/,1 undcuued thatifue building
Jou of c endy ham a semi, that it is my responsibility w nod the occupant of the
mqui Al , hleheprt W priarw, iuuuwe.(.Ccmna � yp.n
Signature of Applicant Date
!/VAI i '����
All roof coverings to be Class "B" or better
owner V f
or wthomsd a p, I Date