08050101 CITY OF CUPERTINO M� .''
BUILDING DIVISION PERMIT P4COl Rk1CTORANF'ORNIt1`fi3O�N.a
w.... :� utrx: i,..n
PERMIT NO.
BmLDtN&9D�g�Ps : DE ANZA BLVD PINN BROTHERS CONSTRUCTIONS 08050101
'S NAME: PERMR ISSUE DAIS
BAY COLONY INVRS II INC 20128 STEVENS CREEK BLVD 05/16/2008
PHONE: 01z r SANITARY NO. CONTROL NO.
(408) 252-9131
ARCHRER/FNGINEER: BUILDING PERMIT INFO
BLDGELECT PLUMB MECH
0 � 0 0
u00 LICENSED CONTRACIDR'S DECLARATION Job Description
C 1 hereby"I m Net I am licensed unr provisions of Chapter 9(commencing P
tJ with Section 7")of Division 9 of Ne Budxv and ftletsiam Code.sd my licensee REV, REPAIRS TO EXTNG NON—STRCTRL CEILNGS
n n in fall farm and effort
License Clan, Lic.g @HALLWAYS ORIG#05100154
3F Da, Centramr
e ARCHITECTS DECLARATION
e 1 underwnd my plass NW ha used as Public records
JyU
yG Licensed professional
5 OWNER-BUILDER DECLARATION
E Q 1 hereby.Rion Net 1 1. .B rept from the Contractors L:Any c Law far the,
p o fallowing reuon.(Section Tinca I.S.Business and Pmfesaiom Code:Any city ar county
1§P whim require•permit a cat.this ober,improv,demulm,fi mPmi any ameum
_xi Priorb sl jusenum,Worwuirn rha vision of far such mover'p file.s Laedwmmem
E (comthat mencing
ening cdpuretion7 )ofDiviass 3ofamf are Burins adPrefusso Chapter Sq.F[. Floor Area Valuation
y�$
dent
be
wno therefrom
ad of Divuionr of am Business ad My
Code)of
Q Nu ha V ee1.5 b therefrom.nal the burs for Ne alleged exemption.Any l Pen in of
.1Section
more
a then by any applicant far a permit subjects Nc applicant N•civil penalty of N Number Occupancy not mom thio five hordes dales,(SSUB). 3 2 6-10-0� P Y TyPe
❑I,uawssraftW Proputy,ermY eoPloycn with wgnudev role compessadon,
will do the wodL Nd Ne smcture,is not Intended eroReted far ads(Sae.]OM.Bust•.••
sed Prefestiru Cade The Coouxrars License Law area at apply in n rare of .. - Required Inspections
Import wha Wilda ar importer Nermn,,ad who doesrueh wart himself ar through his
awn employees,provided due such improvements me rot accident oroffered for sale B.
however.Ne Wilding or improvement ismid within arc Poor of comphoim,the rvmer-
bullde will haw the burden of proving that W did net Wild or improve for pwpos,of
sale.)
a wno f Ne property.em uduiwly contracting with Banned tmnuumm an
on tW m(Sec.]DN,Bud.as sed Prafectlaru Colic)ran Conuxwfs U- .
ewe Law d y he v owou rf prvpeny wha Wilds or unproven Nemom.nod
who conaac f ouch jccta wiNacrnuwc'ortUllassed purnum bNe Cdnumtors
GeV
sac p ,Bk PC fu Nis mo.a
Da (YI y
n
R COMPENSATION DECLARATIONoN
1 bembY rm under prsWty of perjury au of the following declarations:
I h``w and vi l malnuin a Cenifinu of Cansem m self-issue fu WortcrsCompcn-
uBn. p'7
Ter by Sudo.3'(BB e(the Labor Cade.oar Ne perfomnce of the
vrerk to which pumllisiuucd.
❑I have ill maintain Workers Compensation I...u rwu nal by Section
37BBof Ne la6a Code.for the pcnomaue of Ne were fer which this permit in issued. '
My Wartces Compensation Issunnce carrier and Policy number w:
Carrier. Poll,No.:
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(Ibis an used ewtbecample¢difth permit la feroru hundmddolfua(SIBB)
or lar)
1 nnifv Natperform ore of the wort for which this Permit b issued.I a 0l nu
employ any. nnym nrmrait a! ubjeettothe WorkerscompessaBn
Laws of Cal' sur
Applicant
NOTICE A ..l making this CeniRam of Exemption.you should
buome. jem the Workers Campo moon proved.of the labor Code,you mora
.J O foMwimh omPl with aub provisions or this permit shall W decmW rooked.
'Z " CONSTRUCTION LENDING AGENCY
r
(-+
]he Yifrm Nam Nem iscosswninn len ding ageuy for the pertomena of
6i> theLe work ser whim this u
s peLaurel(Sare)
.709],civ.
Le '
4 A nders Nun ,
�z Lendeh Address
U O 1 m ry,Nam 1 have read ars applicadn aM .in this the,have imfrrmsume is .
Ly correct.I agree m comply with all city nod county ordinances and mate laws relating to
O Wildhngcouwed. nod hembyunhodm mpmmnta we;of Nu city to enprupnn the
-mntlmpd nY Ter impacts.
ofthis pepiL -
y (We)agree t ve.indemnify ad keep tameless the City of Cupertino agalsst
fI1 i litiu,judgmcna as ad eaperuu which may N say way aceue agams,said City
U,'� n eerce of the AN ar this D l
ICANT U E STANDS AND n:CCOMPLY WITH ALL NON-POINT Issued by: Date b,.,mR
U s
Re-roofs
Si a li for Doc
DOLS MATERIALS DISCLOSURE Type of Roof
Will lie applleat m future Wilding aecupntaore er handle hauAous material
and by Nc Cupertino Me Code.CbaPrcr 9.11.orb the Health nod Sorely
. em 25532(.)] All roofs shall be inspected prior to any roofing material being installed.
0Yu e
Will the applicant or future Wilding occupant um equip nee'or devices which If a roof is installed without first obtaining an inspection,I agree to remove
emit huudnn s l cnumiruna u Rud by alp Bay Arta Air Quality Managcmcnl all new materials for inspection.
District]
❑Yn u
I adNc matarisi nofhomenlrunder Chaprer6.95afdpC.lifor-
meHeal S ei,crdc. 25505,155]7 and 25534.1 unersuM lha if the Wilding
don rpt y have! L it u m IBry b necify Na rampant of alp
war t uane.rseerd o0 Signature of Applicant Date
Ower or..imn,td a cut Q,mI All roof coverings to be Class in"or better