05090133 CITY OF CUPERTINO
BUILDING DIVISION PERMIT '110 T12e CT I2I,NF0 .. ATTIOIV`;O!,,`s
BUILDING ADDRESS: PERMIT NO.0
10550 S DE ANZA BLVD
&RME. PERMIT ISSUE DATE
'
URS-ARCO 6747 SIERRA COURT, STE J 03/30/2006
PHONE: SANITARY NO. CONTROL NO.
(925) 551-7555
BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
Boo LICENSED CONTRACTORS DECLARATION
I hereby Affirm that I am licensed under provisions or Chapter 9(commencing Job Description
i wish co,100,� ol�1,loojllTd.�.Busunes and pre"O" TI-GROUND WATER TREATMENT SYSTEM
to I�
foret. �,ce
License as eig Lan if h_
Dam
omm�
C , rS I to W 3/14/06 ADDED COPY FEES $4 . 00 (16 COPIES) NOT
D RATION
I understand my plans shall be used as public records
Licensed I'm(cssional
OWNER-BUILDER DECLARATION
I hereby afflore that I com carrept form On Contractors License Law far IN
CoO following memo,(Section NO 1.5,Business and Professions Calc:Any City or..my
which rcc,uircs a Permit to construct,after.Improve,demolish.ore any structure
prior to its issuance.SIR,requires the applicant far such Permit to rite a signed statement
pp that he is licensed pursuant to me,provisions of Man Conuscones Uccom,Law(Chame,9 Sq.Ft. Floor Area
(Coarno neing with Section 70DD)ofovision 3 offt Busfincomand Professions Code)at
Wt Me 0 rusempt thernfron,and the basis for Me alleged musneption.Any violation of "aft 0 0 0
Section 7031.5 by a"applicant for.Permit Subjects the applicant I Civil Penalty Of APN Number U Ur w:�tL ccupancy Type
not..rt them five hundred dollms(11500i.
[]1,an Owner of the property,or my employees with wages as their SOM Compensation. 169-iRnn2. . ()n
will do the work,and the structure is out intended or.fted for sale(son.7044.Business fNnsgections
and Preftecarms Code:The Corouscures License Law door set apply M an comer of Require
property wine Wildswinaparmse,dourcon,and whodoessushwarkiflactelror through his 4uuo
om employces,provided that Such Improvements are not imended oroffered fagam.If•however.the building or improvement is Sold within one year ofcompledon,the Owner.
WiMer will have the burden of proving that he did not build or improve I"purpose of
Sure). Rblk
0 1.as Owner of the property.am"elusively contracting with licensed contractors to ONK;
Construct Me posoca(See.7044.Business and Promoodoes,Code:)The Contracurr's Li-
sue Law does OOL apply to AR owner of property who Wilds or improves motor,and
who contracts for such projects with a conuouclorm)licensed pursuant to the Com-aclar's
Lk.a.Law.
0 1 am exempt mum,See. _.B Sk P C for this Mason
Ft Dam-
WORKER'S COMPENSATION DECLARATION
I homby Affirrat under penalty of perjury am of the following dechuations:
❑I ban and will maintain aCestifictum of Consent to self-Insure forWorkers Compon.
sation,an provided for by Section 3700 of Me Ldarr Code.for She performance of mc
work for which this Permit Is around.
0 1 have and will maintain Workers Compensation Insurance,as required by Section
3700 of me Labor Code,for the performance of the work for which this peornift Is issued.
My Workees Compensation W;umcxds 'a and Policy a
FT Policy No.•
CMl� ATE OF EXEMPTION FROM WORKERS'
?OF
COMPENSATION INSURANCE
(Thissecdom mod notaccounpicaud if the Permit Is forms,hundruddallars,($100)
Or MSL)
I cartify that in the performance of the work for which this Permit Is Issued.I Shall net
employ any Person in any mnncrm as he become subject to the Workers'Compenumdon
L,m.f California.Date
Applicant
NOTICE TO APPLICANT.If•afar making this Ccrifficam,of Exemption.you should
become subject m the Worker's Compamation provisions of the Labor Code,you must
z forthwith comply with such previsions or this Morris shall N damned Invoked.
Z 0
CONSTRUCTION LENDING AGENCY
W
I hereby affirm Oat Nem is a Construction lending agency for the performance of
Isi the.6> it for which this permit is issued(See 3097,Civ.C.)
,
leucins Nam
O. Lemice,Address
U;D z
0 1 certify that I have need this application and SUM that Me above Information is
T,, correct.I agree to comply with all city and county ordinances and sum laws miming In
0 Wilding construction,and hereby Itutharice rnpresentatim or this city to cnWr upon use
show-ormirmcd PaOfauty for MSPCCLom PUTPOSCS.
(WO)agree in Save,inalmordity,and keep harrems,the City Of Cupertino against
req liabilities.judgments,cuts and expenses,which may In any my accome against Said City
U Z in consequence Of the granting Of this Permit.
APPLI ST COMPLY WITH ALL NON-POINT Issued by: �eaDate -7.,
SO=! ANDS AN MPL
A
U ez W2 224 w"/_e Re-roofs _C7
Signature OVIL954V=CIOr Dam
ARDOUS MATERIALS DISCLOSURE Type of Roof
Will the applicant or rumm building occupartsome orbardle hasommm material
as defined by the Cupertino Municipal Code.Chapter 9.12.and the Health and Safety
Section 25532m)? All roofs shall be inspected prior to any roofing material being installed.
DYCS . If a roof is installed without first obtaining an inspection,I agree to remove
Will the applicant Or future Wilding Occupant use equipment ar devices which
am],hazardous air contaminants as dcflncd by the Bay Area Air Quality Management all new materials for inspection.
District?
0'ros DAM�
I have mad the Imnandowsmaceflals requirements underChapW6.95ofthe Califar.
nia Hear"SapctyCodc.Satires 15505,25533 u125534.I urelconand that ifMC building
does.1 murcully have.useart.met it 4 my responsibility 0 nruf,the occorman or the
raySignature of Applicant Date
,,dh
Z4dK,.-d ant All roof coverings to be Class"B"or better