05090230 CITY OF CUPERTINO 'i '�saa 5°:
BUILDING DIVISION PERMIT �CONTRACT�ORINFO SMA.TION
BUIL DING ADDRESS: GRANITEROCK CO.c PERMIT N005090230
1505 S DE ANZA BLVD
a NET'S NAME: PERMIT ISSUE DATE
GRANITEROCK CO. 09/30/2005
E:
SANITARY NO, CONTROL N0.
ARCHITEC(ENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
0 0 0 0
u00 LICENSED CONTRACTOR'S DECLARATION JobDescri Description
tit 1 hereby affirm that 1 am located under provisions of Chapter 9(commencing P
�i with Section 7")of Division 3 of the Businai mdP afcyiam Code.mdmylicenmis
n<> in full force and effect GL)_ REVIISON--WALL ABOVE MEZZONINE
5q_ License cl - Lia a'
Ct Date Contractor n G NO NEW PERMIT ISSUED/ORIG. ${05040152
}�M1TELT$�3,q�FECCLARATION
fund., ndmy )a hatkbe sujjj qi. ret
JyU �
s Q Liccnud Tcssi al
a 3 OWNER- UILi)ER DECLA TION
<q I here y affirm OZN1 am cacmpm from the Co rs Liccnu Law far the
x O o following mason.(SCcom IID LS,Business and limfr siore:Cock:Any city or county
$lei wM1ich rtquita a permit m ennswet.alter,impmw.Demolish,of repair any structure
prior m its issuance,also requires the applicant for such permit to file a signed natemcnt
that he is licensed pursuant lathe provisions ofthe Contractor's License Law(Chapter 9 Sq. Ft. Floor Area Valuation 35
xi-C' (commencing with Section 7")of Division 3 of NC Business and Profcamons Code)or
y Nat he I,Bumps therefrom and the bazu for the alleged in entptioo.Any violation of
Section 7031.5 by any applicant for a permit aubje.the applicant I...I,!)penalty of APN Number Occupancy Type
not more Nan low hundred dollars(M). 36610121 . 0 O
0 I.as owner of the pmpwy,Carry employees with wages as their sole compcnsadon,
wuldothework,and destruction n iolimanind oroRered forsale(Sec.7044.Bwamms Required Inspections
and Profeavions Code:The Contractors License law does not apply to an owner of q P
property who builds or improves thereon,and who does such work himself or through his
own employees,provided that such improvements arc not intended or oneud for mile.IL
however,the building or improvement is sold within one year of completion,the owner- C�
builder will have the burden of proving Nat he did wt Wild or improve for pursepoor
sok.).
❑I,as owner of the pmpeny,am exclusively contracting with licensed conussmrs to p
convect the pmject(Sec.7044,Business and Professions Code:)The Contra<mr's U
.erne Law docs not apply to an owner of property who Wilds or improves thereon,and
who contracts for such pmjecu with acontractpr(s)licensed pursuant o the Cencomnirs V {�
License Law. J
❑1 am exempt under Sec. .B&P C for this mason
el Data
WORKERS COMPENSATION DECLARATION
1 hereby affirm under penalty of perjury one of the following decimations:
1 have and will maintain a Certificate of Consent to self-insure for Workers Comport-
cation,as provided for by Section 37M of the labor Code,for the performance of the
work for which this i mit is issued.
1 have and will maintain Worker's Compensation Insurance,as required by S.ction
37W of the labor Code,for the performmee of the work for which this permit is issued.
My Workers Compensation Insurance Cartier and Policy number tic:
Cartier. Policy No.:
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(TTis section need not be completed if i W permit is foranc hundred dollars($100)
or less.)
1 certify that in to performance of the work for which this permit is issued.I shall nor
employ anyperson in any manncrso as to beeomc subjecuo dne Workers Compewtion
Laws of Caliromis.Date
Applicmt
NOTICE TO APPLICANT:IL after making this Ccn rium of Eacmption,you should
become subjea to the Worker'a Compcneelion provisions of Ne labor Code,you muss
.J O forthwith comply with such provisions or this permit shall be deemed revoked.
'Z N CONSTRUCTION LENDING AGENCY
�-. I hereby affirm that them is a construction lending agency 1'nr the performane,of
Cthe work for which this Permit is issued(Sm.3097,Civ.C.)
0.Q Lenin's Name
D Lenders Address
U Q 1 cenify that I have read this application and some that the above information is
W F-r colon.1 agree to comply with all city and county otdinan es and state laws miming to
0 U building Conswctionand hereby authorne represcroadws of this city to enter upon the
fdl move mentioned property for inspection purposes.
4. (We)agree to saw,indemnify and keep harmless the City of Cupertino against
Fto liabilities,judgmcnss,coma and c.,.which may in any way...against said City
U Z in consequence of the granting of this permit.
^ APPLR NO ND WILL COMPLY WI�U.-NON-POINT Issued by: Date
SOICAURC ELL
Re-roofs
Signslar ! plic MC Dem
ARDOUS MAT ALSVISCLOSURE Type of Roof
Will thcapplicantur filum bui �upiman.m or handle haresdous material
Otter?
onned by the Cupcnino Municipal Codc.Chapter 9.11.and the Health and Safety
e.Section xss3z(a)r All roofs shall be inspected prior to an roofing material being❑Yea ON. P P Y 8 g installed.
Will the applicant or mtnm Waxing omnpant mice.equipment or dwim wmm� If a roof is installed without first obtaining an inspection,I agree to remove
Jt hazardous air contaminants as defined by the Bay Area Air Quality Management all new materials for inspection.
_
❑Yes ON.
I have ranlrms materials requitcmcnu under Chapter 6.95oftheCantor-
niaHCalth afetyc batsnS05.25533arn125534.lunde dthuifft Wilding
docanot ulontlY, ten a is my responsibilitybafy did bee
Pantorthe
myu/m .rat
Own aathnareaa fit a t fir a ntit?tBtrreflpce�. Signature of Applicant Date
�iC/!� Date All roof coverings to be Class"B"or better