08010100 CITY OF ERT
BUILDINGCUPDI VISION PERMIT CUNTRAGTQRINFORMATION `.
PERMIT NO.
BUILD�Np9n V'b DE ANZA BLVD FLR 1 NOVO CONSTRUCTION 08010100
WS NAME: 1V PERMIT ISSUE DATE
FORGE & CUPERTINO LLC 1042 HAMILTON CT; 05/08/2008
PHONE: (650) 701-1500 SANITARY NO, CONTROL NO.
ARCHIECflENGINEER: BUILDING PERMIT INTO
BLDG ELECT PLUMB MECH
300 LICENSED CONTRACTOR'S DECLARATION O O
f Fpy 1 WK1,Y affirm that 1 am limmN under pmvisans of Chapter 9(wmmusabs Job Description
with Secllon 7WO)ofoiviaion 3 arum Buunrsst and Prefaainm Code."my ticenx is REVISION TO UPGRADE RESTRMS PER ACCSS COMPLNC ORG
p m m full force and ef(
A2 Llcenrccl -' Lm.I 07090163 NO NEW PERMIT.
7 Dam ConDECL
e id, 01,11r) cam
ARCHRW unbc DECI.AM ON
e� I uMernand my plans shall he used as puhlk rocnrM
x6
k G Lleeosed Professional
S3 OWNER-BUILDER DECLARATION
a��2 1 hereby afrum that I am caompt from Ind Cmaractofa Licenx Law for Ne
E2
O following won.(Section 7831.5,Butirwss and Pmfessioro Cade:Any city m County
m 2 which inquires a pound.to..ruuu ,alma improm,demolish,or¢pair,any s nsclure
_iy prior u,its issuance.stw require the Applicant for such permitm file s signed natement
F <
that Wislico.sedpursuant toNeprovimomolthoContractor"L,CmoLow(CliaPter9 Sq.Ft. Floor Area Valuation
y 3 (commenvng with Section 7BOB)of Division 3 Of ft Sti m s it Prafetsiw Cock)or $708523
and M Is exempt therefrom and ute basis for the alleged memption.Any violadan of
Section 7031.5 by airy applicant for a permit subjects Ne applicant m a Civil penally Of umber Occupancy
not mon,Chad Infin hundmd dollars(SM 3 I 6 0 21 O 3?F P Y Type
0 1,u owner of the pmpmty,sur my mployen with wage a Neirmk campenndon,
will do thework and Iheswnme u notku ied or.11mul bonds(Sec.7 .Busi.
and Pmfossloos Cade:The Conlrac do's LieenQ Law dolor not apply in an Owner of Required Inspections
property who Wllosorlmprostat an,aM whodacasuclt work hlouelfmthrou,h his
own employee,provided thmsuch improwmerm art notimmnded aroRered for sale.If,
however,um building Or improvermms,B sold within arc your of cmepletion,um owner-
builder will haw the busdrn of proving that M did an,Wild or improv for purpose of
sale.).
0 I.as owner of the property and caclusinly contracting with licsm ul Contracmn in
concoct Ne project(Sec.7014.Business and Pmfeakos Code:)The Conoacmr'a U.
Cow law does not apply m an Owner of property wits,builds or Improv therecn,and
who contracts for such projects with a Contracnm(s)Bondi pursuant in Ne Conoadora
Liceve law. ..
r 0 l cam mempt under See ,B&P C for this
Data
WORKERS COMPENSATION DECLARATION
I hereby aRlm under pooalty of perjury one ague following decla..6.
1 have aM wRl mainuin•CertiOcamaf Corvert m self-imurt fa WaM1efsCanpen-
section,as provided fm by Section 3700 of the labor Code.(or Ne peRannenCo a(IM
work for which this permit is isvtcd.
0 1 have and will maintain WorkeYs Compensation Wuram,as natuirW by Section
3700 of No Iaborcode,for the perlormam of tiro work for which Nts permit is Lamed.
My Wor e.N�i L Inwood ppim��a(5wOdd Policy numbe((r__am: /A 0�'I
Carrier. I�R<✓1 Phliey No.: I w-)?-04-1 I
CEIITIFICATE OF EXEMPTION FROM WORKERS
COMPENSATION INSURANCE
(This==.neod fur ha completed If the .it is for.hundrod dollars(SIM)
orksv)
1 cenifY Nat in No perfundr.of the work for which this permit ts issued.1 sIW I am
employ any person in any manneran as to become subject in this Wortcn''Comperuauon
Laws of Califon is.Data
Applicant
NOTICE 71)APPLICANT:IL after making this CcnlOcam of Exemption,pais should
become Union in the Worker!Componation pmvisions of Nc labor Code,you most
.J z fanhwiN comply with such provisions Of this pent.shall be dO mcd molted.
zy . CONSTRUCTION LENDING AGENCY
[-+ 1 kichy,ahem the them u a ommoctinn Lodi.,a,emy for um perfurmanm of
C'> um work for which the pemtit u Lssned(Scc.3097,Civ,C.)
A Undoes Name
z Lenders Add.
U O 1 mti(y that I love mad Nis wlic d.said sum Nn Btc above iafomudun is
(y H CanecL I agree to comply with all city and county ordinsmms and sum laws mladng to
Q U building connnction,
anal herebyauNmiro reprmenlasKs of this city in onto upon the
abuw-mentioned property fm inspection pure mu
(We)alms in ave.indemnify and keep harmless Ne City of Cupertino almost
rq liabilitin,judgments,costs and experun which may In any coy acerae against said City "
UZ
�OUH
�TW'
Ns penniL A D W LL COMPLY WITH ALL NO -POINT Issued by: DaterIQA Re-roofs
Signatureo pplcanVConomor Visit, /
HAZARDOUS MATERIALS DISCLOSURE hairs Type of Roof
Will umapplicantmfM buildingoccupantr9,1m anodic hawdousmamrim
dc0See by 25 Cupertino Mum 1 Code.Cnapur 9.11.and Ne HraIN and gaiety
.section zss3x(.)7 All roofs shall be inspected prior to any roofing material being installed.
❑Yin Nu
Will dm. Baht or futum din Occupant are If a roof is installed without first obtainingan ins-ection,I agree to remove
PP i P Wuipmcntot Mmagwnich P
emit hvarMm air contaminats dcRutl by the day Arta sur Quality Managcmem all new materials for inspection.
DISV1el]
0Ym No
1 have mad Ne ha uemu muscrims K,,immew undachap,,6.95 aide Califon.
niaHulth&SaIerYCadc.Secdous M505,25533 mdx5534.1uMcrsund NnifNc Wilding
does rot cummdy naw a m uct. Il 4 my INlity m nedry the oavpant of the
mqutmmentswnih ter, et gtm4p r:cndr..Oracmpaney Signature of Applicant Date
ow1> iAagem l%v�(/� Dow All roof coverings to be Class'W'or better