06050134 CITY OF CUPERTINO r mw7v'"t"'
BUILDING DIVISION PERMIT t ,G�UNTRACTpR INFUP`v1�IATT`OV
BUILDING ADDRESS: PINN BROTHERS CONSTRUCTION rMITND'06050134
10745 N DE ANZA BLVD
OW NER'S NAME: PMUArT LSSURDATE
BAY COLONIES 1475 SARATOGA AVE OR/18/2006
NE: SANITARY NO. CONTROL NO.
(408) 252-9131
ARCHITECT/ENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
;op LICENSED CONTRACTOR'S DECLARATION Job Description
hereby affil m W,1 aRo
m amed under Pmvial of Chapter 9(commencing
t,T2 wM Section 70110)of Division]of dm Business aa&a fesiona Code,and my license is
sow a full��rte ase eneeL 3:920 TEMPORARY PERMIT FOR PODIUM ONLY
ordere
r. cmnmar f— EXPIRES 6/17/06
7ARCHITECTS DECLARATION
erstan
I 1 understand my plans shell W hand as public mcards
> U
Licensed Pmfeuiaml
OWNER-BUILDER DECLARATION
af I hereby.(Ilam that 1 am1. ,Benne Item the Catheter'. :My c taw for the
D o which
meson. emit 1 ]011.5,Bualwe and w.deo um Cad,:My city or county
$ which its itms a ,also n him the altar.ImProw,dcmnl4t sir minor any structure
priarbiu Wswnco.alw mquima the applicant for each permit mfile aalgned mtement
€< Lha,he ulicensed punuanllolhcpmvialomaf Use Conmeura Liceve uw(GapW,9 Sq.Ft. Floor Area Valuation $0
$ named
Senf=and sir Win
far of alleged
legasrandar.My NCade)or
.- Nat hr u exempt timmfrom and de beau for the allogod exempuam My WabUon of
SeNan 7011.5 by any applicant for a permit mbjecu the applicant,in a civil penally of pEN Number Occupancy Type
.at mom Nan R.hundred dollars(55M 3 2 610064 . 00
❑1,an owner of the property,w my wpdoycea with wages as their nate compensation,
will do the work and due muctum is not intended m0ared for Gain(Sec.7044,Busiwov Required Inspections
and ProWdom Cade The Conuenora I amu use dn ono(apply ine an owner or q P
property who build,or improves Lhemon.and who dommichweak himne(for through his
awn employcea,provided ftt=h impmwmenu an notiniended oraRend imine.IL
Instrument,the building or improvement Is mid within ane year ofc°mpledon,me ownes-
buildn will have the barriers of proving am[he did no,build Or imi m e for purpmen of
sale.),
O 1,m owner of Lha propene am ewtusivety eonuattting with licensed conuacton to
consumes the project(Sec.7044,Butinm and Professions Code:)The Contractor's U.
mass taw dons not apply to an owner of property who builds or impmwa theman,and,
who contracts for such project,with a ennuactar(O Rwued possession in the Gnusctara \`
License taw.
❑I un eumpt under See ,B At P C far this mown -
Owner Dau
WORKER'S COMPENSATION DECLARATION
I hemhy amen seder penny or Perjury Graafian following enamor am:
I haw old semi,malnuin a CeNfinu ofComent to self-usum for Workers Camper-
ion,as provided far by Section 7700 of Ue Labor Code,for Lhm Performance of Ne
work for which this pmmlt Is banned.
❑I haves and will maintain Workers Compensation Imurann,an required by Section
37W of Ne Labor Cade,for the Prof...of dse wart far which this permit in hued.
My Woder's ompe sauonlmun cccor Brand Polie nu be
5 Polf �gre'
Lader. r4 V`K.G✓ ry No.:7/
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE v
(Thu wcdm wood nation completed HUe permit is forone hundred dollen(5100)
nr int)
1 certify that in the perrournmm of tite work per which this permit is Wood.I shell tet
employ any person in nay an........an to became subject in Lhe Worken'Compensadom
taws of Cmfhmda Data
File font
NOTICE TO APPLICANT:If.after making this CeniRnm of Exemption,you should
became nunna w N.Wohera Compensation pmHuons of Use Labor Calc,you most
.J O forthwith comply with such provisions or Nu permit"I be domed lowland.
Z CONSrRucnoN LENDING AGENCY
y
[—i I hereby arm that Nom Is a com,ncdnn leading agency far the perfennueo of
C> Ne were for which Wa Permit is issued(Sec.7097,Civ.C.)
Qunder:Name
2 Lenders Adds•..
U0 I certify Na,I haw read this application and sum Na,the show Information Is
17.f"' comem I agree to comply with all city and county ordinances and sun laws miming In
0t) building cm,emetioq and herebysuNarim reprmenutives of this city n enter uPat the
G ahhve-menuaned property for inspection ptare ms
(We)agme to save,indemai fir and keep harmless the City of Cupertino Maim,
tit,A liabilities,judgments.taus sed expenses which may in nay way accrue Maim,said City
U 7 In coLICANT ofthe grSTAND this permit. y, ^O�
C• APPLICANT UNDER67AND tD WILL COMPLY WITH ALL NON-POINT Issued b6Date f O-
SOURC NS
sign mafApOlfcon an(racmr
S'119106 1Re-roofs �—
HAZARDOUS MATERIALS DISCLOSURE Type of Roof
Will the appllmntor fumes building occupant nam or handle hazardous material
as de0wod by the Cupertino Municipal Cade,Chapter 9.11,and the Hath and Safety
Code,Sued.25532(a)? All roofs shall be inspected prior to any roofing material being installed.
DYes )<No
Will the applicant or fumm building occupant use equipment or devices which If a roof is installed without first obtaining an inspection,I agree to remove
It hazardous.I,conuminanu as dented by Ne Bay Area Air Quality Management all new materials for inspection.
ieuin?
❑Yea 3jrNa
I have and the hamadmumamdaumquimmcnu undcrchapmr6.95 of Lha Califor-
niaHealNkSarmyCode,Sectios 15505.15531 and 25534.1 understand thuirtne Wilding ,
does oat curmn11 how a tensed Wt l,' m mmpomihili,Y m noury the occupant or the
mgNmmen be me ten,° crnifm.mar Signature of Applicant Date
�$
Ownnt Dam aAll roof coverings to be Class"B"or better
eror wth� onmds ,i "