06060111 CITY OF CUPERTINO s' + � �+av§u2 tW^'�777777'
BUILDING DIVISION PE MI h
R.94,E
BUILDING ADDRESS: o PERMIT 00-0606 0 111
10745 N DE ANZA BL ihl� QkS ei
ONR'S NAME: PERMIT ISSUE DATE
BAY COLONIES p$ - /3I06/14/2006
E: SANITARY NO. CONTROL NO.
ARCHITEC(ENGINEER: BUILDING PERMIT INFO
eLDOO O PLUMB MECHO
uoG LICENSED CONTRACTORS DECLARATION Job Description
vd 1 hereby.111.MWt I am ficamd under pomismos of Chapter 9(ummencln{
with Sudan 7000)of Division 3 of the Business and Professions Cade.and my license u
+� mmnfarecandeffeca TEMP PERMIT EXTENSION-SEE ORIG TEMP PERMIT
CisDoI& - c« wr FOR INPSECTIONS-PMT ONLY ON THIS ONE
f. A CHITECTSDECLA A ION
U 1 undersand my Plats shall he used u public records
k�4 Licensed Pralloa mal
`m OWNER-BUILDER DECLARATION
i I hereby elfin t that I am exempt Imm the Conuenm's License law for the
O o following moan.(Sccdan 7131.5,Business and Profossiuos Code:Any city or county
S$g which requires a permit to constmcL dmr.improve,demolish,or repair my swcmac
zi prior in is Won=,.lw requite the applicant forsuch permit to file a signed!satement
�< that he is licensed pursuant to lite pmvismas of the Conusctur'&Llceosc lAw(Chapter 9 Sq.Ft.Floor Area Valuation 0
$ (cournmaMg with Section 700D)Of Division 7 of the Business and Professions Code)at
Nat he b exempt Mao:hom ad the bub fm the alleged exemption.My viola lon of
Sedan 7031.5 by any applicant for a permit subjeca the.pplmmt to a Civil penalty of yNvi r� Occupancy Type
not more dun five hundred dollars(5700). 3/��i,,0�6 4e. 0 0 CCU anC e
❑1,as owner of Ne property.mmyemploym with"Sum
tele eompensetia, G lUU(�
will do the wok and MCA==is atmmnded oranered fars.la(Sec.7044.1usimae Required Inspections
and Praresdons Cade:The Cantrucmr's License dm at apply to a owucCr of q P
pmonywlebuildsmimproves Nem m.andwho dmsuchwork him a ror through his
own cmploym,provided that such impmamenu art not Intended oroRcred for We.14
however,Ne building"Improvement is aid withinotm year of completion.Ne owner.
builder NB have tite burden of proving Mae he did vol build or Mpro a for purpose of
sem.).
❑1,AS owner of the property,am exclusively contracting with licensed cenmmms to
mmtruct the project,(Sea.70".Business as Professional Cade:)The Concretizes U.
cove!Ase dm not apply w ts owner of property who sed p or Improves Norton,and �\
who se Law.for well projects with a contramor(s)licensed pursuant m the Contractors
0 1 ser Law.
❑tem exempt undo set ,BKPG for this moon
Dam
WORKER'S COMPENSATON DECLARATION
I hereby affirm under Penalty of perjury One of Ne following dechumdoos:
I have and will maintain a Cenifieam ofCoosem m alf-woure fm Workela Cmnpen.
aflon,u provided for by Section 3700 of the Labor Code,for the performance of the
work for which this permit is issued.
❑1 have ad will maimon Worker's Compensation losurtuce,As mquirtd by Sudon
3700 of Ne Labor Cods,for the performance of the work for which was permit is laud.
My Workers carepeeudan lowrance Cartier and Policy number are:
Cartier. �/'f RYti 2 Q Policy Nm:A / 3 f/
CERTIFlCAT ;O —EMMON FROM WORRIERS'
�—
COMPENSADONINSURANCE
(nth inion need net be completed If Ne Permit Is fmone hundred do0au(5100)
or Ins.)
1 unify Not in tite performauc of Ne work for which this Permit b lamed,l shell tet
employ any paten In my mormerso As in became mbjat w the Warkcrs'Comperevatian
laws of Califamia Date
Applicant
NOTICE TO APPLICANT%If.after making this CCrtlfeale of Exemption,you should
became subject to the Workeh Compensation provisions of the Lahm Cade,you most
,J Z forthwith comply with such provisions Or this permit atoll M deemed revoked.
7 Q
q y CONSTRUCTION LENDING AGENCY
[-. IMaRimivias baeoavucOnnwain{agency fm NepMonnaruu of
CL work fur
which
which Nmrmitit peb issued(Su.7097,Civ.C.I
Le '
�W Lender's Name
7� Lender's Mdmas
V Q I=try that 1 have read this application and saw that Ne ebow Information b
U.r comm l ajme m comply with all city And county Ordinances soul Nm laws relating e
Q V building convection,ad herebyauthosia mpmanatim of this city to enter upon we
(1d ahovc-mentioned property for inspection proposes.
(We)ego to ase,indemnify ad keep hanowss Ne City of Cupertino agsiost
liabilities.jagmems,costa ad expenses which may In any way amuse&gaunt avid City
Uin consequence of the granting of this permit.
APPLICANT UND RSTANDS AND WILL COMPLY WITH ALL NON-POINT Issued by: Date
SgUTAREGU ONS
`("&� ac --�� 6- ly Re-roofs
Signature ofAWliam/Con rmar Dam
HAZARDOUS MATERIALS DISCLOSURE Type of Roof
Will the applicant Or rutwe building occupatwae m male h ous material
dented by Ue Cupertino Municipal Cade.Chase,9.13.ad the Health ad Safety
'e, [j yes Sectio 25532(.)7 Ito All roofs shall be inspected prior to any roofing material being installed.
Will Ne applicat at future building accupam taw equipment Or ticvim Mich If a roof is installed without first obtaining an inspection,I agree to remove
7md
t haaadnos it,s'onuminana u defend by the Bay Area Air Quality Mmagemcnt all new materials for inspection.
fict7
❑Ya KN.I haw mad Use hmados amaterials mquimmeno underChapter6.95ofNeCalifor-
HealNkSafetyCode,Suctians25505.25533 as 25534.1 undermostthsilfthe building
not cwwntly haw a mmthat u w
It b my responsibility modify we occuptat of the
ummems which must be met prior w iauau of a CCNfcate of OcwpmCy. Signature Of Applicant Date
Owner car IUMOH ed agent Date All roof coverings to be Class"B"or better