05090108 CITY OF CUPERTINO nx�rxWs na •• ,$^�«z( +arra"., 't,a' v. : a,<y
BUILDING DIVISION PERMITCONTRACTORoINFQRMATI,QN '
BUILDING ADDRESS: DOLINGER PROPERTIES PERMI714005090108
1601 DE ANZA BLVD 4 230
OWNERS NAME: PERMIT ISSUE DATE
DOLINGER PROPERTIES 09/15/200S
E: SANITARY NO. CONTROL NO.
ARCHITECT/ENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
0 0 0 0
u o o LICENSED CONTRACTOR S DECLARATION
til FF 1 hereby grimdeal I Am licensed under provisions of Chapter 9(commencing Job Description
Zly with Section20(kB of Division 3 of the Businvi and Professions Cock.and my license is
n<n. mmumaamaarr TI-OFFICE SPACE, NONrBEARIN AILS
n`lj�? Licenu Class -Lic.M 4 ) II fns\ [kpJ[uV�JJ�
Date Can,,, r I' ter ( �;
Z ARCHITECTS DIMRATI N u \�f'\',Ler
ey a U I understand my plans shall Ni used m public records
s
w t, Licensd Professional
`03 OWNER-BUILDER DECLARATION L o 2005
Y 1 hereby mTrm that 1 am asampt from the Contractor's License Law for rise
00 fallowing mason.(Section 703 1.5,Business and Pmfessiuns Coder:Any city or county f�a n tet
<s ff whim truf iris.permit to coons t els,,improve,demolish,nr rtpoi,any stmemm H ,f P 9� II W.. A N n kP� $158503
prior in its issuance,also requires the applicant for such Permit o file asigned statement !1' l'�� I�, t�j u,l "1'1
X< that he is licensed pursuant to the provisions of the Contractor's License Law(Chapter 9 Sq. Ft. Floor Area Ud ,al-� 'J.L, uvJlt /Valuation
xi-O (commencing with Section 2(XXy of Division 3 of the Business and Professions Code)or
y $ that be is exempt therefrom and the basis for the alleged exemption.Any violation of
Section 7031.5 by any applicant for a permit subjects the applicant to a civil penally of Occupancy Type
AM more than five hundred dollars(13(10).
I,u owner of Ne property,of my employees with wages As their sole mmpcluadon,
will do the work and Ne.wcturt is not inmWed ororRsd forsale(Sec.7044,Business
Add Professmas coda:The Commomes LicensLaw does no,apply by owner of Required Inspections
property who buildsorimproves themon,and who does such workhimself or through his
Own employees,provided that such improvements are not intended oroRcred for sok.If,
however,Ne building or improvement is old within one year of completion,the owner-
builder will have due burden of proving that be did not Wild or improve for puryosc of
Asia.).
O 1,as owner of the property,am exclusively con=ting with licensed cond.etors to
Construct Ne project(Sec.21144.Business and Professions Code:)The Conuslor's Li-
echo Law docs not apply to an owner of property who Wilds or improves thereon.and
who contracts for such pmjccb with a contractor(s)licensed pursuant o the Conuacmr's
Licenu Law.
CD I am exempt under Sec. ,B At P C for this reason
Owner Data
WORKER'S COMPENSATION DECLARATION
Ph1 hereby.form under penalty of perjury Arc of the following derlmiumss:
am and will maintain a Certifies of Consent o ar]Nnsum for WorketsCompen-
moon,As provided for by Section 3200 of the Labor Code,for Ne pedmmmce of IW
work for which this permit is issued.
❑1 have and will maintain Worker's Compensviom Inomne,as required by Section
37M of the labor Code,for the porformmoc,of Ne work far which this permit is issued.
My Workets Compcns tion lnsur camennd olicy number ver:
Carricrt _ NO:
,E_7ss`�33o�
•�• CEkkkk IFICAT'E OF EKEMPITON FROM WORKERS'
COMPENSATION INSURANCE
(This action need not he completed lithe perm.,is far one hundred d.11.41,30)
or IMI)
1 certify that in the Imformenee of the work for which this permit Y issued,I shall nm
employ any prion in any manner so As At become subject o the WorkersCCmpansation
Laws of C.Iifordia.Das
Applicant
NOTICE TO APPLICANT:If,after making this Ccrtificas of Exemption,you should
become object As the Worker's Compensation provisions Cr the Labor Coder,you..at
.J Z forthwith Comply with such provisions or this permit shall be deemed mv.kcd.
Z'O CONSTRUCTION LENDING AGENCY
I hereby affirm that there is a mnswctinn lending agency(or the Performance of
a the work fur which this permit is issued(Sec.3092,Civ.C)
157 Q Undies Name
z Lender.Address
U 1 certify that 1 have read this application and state that the.hove information is
E-' coreeL I agree in comply with all city and county ordinances and state laws relating to
0 U building construction,And hereby authorize representatives of this city to enter upon the
,r above-mentioned podiatry for inspection purposes.
D. (Wer)agree m Aave,indemnify And keep hvmlw the City of Cupertino against
H rZ1 liabiliti]' emu,cos.and cIN,which may in any way same Against old City
UZ 'nc9nscqucncco agnnling ofthispermit.
APPLICANT UN ERSTANDS AND WILL COMPLY WITH A NON- OINT Issued by: Date
UrON q
6 Re-roofs
mCIA"
S' ute or App man" I r Date
HAZARDOUS MATERIALS DISCLOSURE Type of Roof
Will do,.,,]least Cr future building uac.p.at stow.,handle huardous material
As deGncd by the Cupertino Municipal Code.Chapter 9.12,and rbe Health and Safety
Code,Seen..Y.zssu(ar /. All roofs shall be inspected prior to any roofing material being installed.
p Yes LAYN
Will the.ppli.am or for o¢wading occupant use equipment or de.iaes worn If a roof is installed without first obtaining an inspection,I agree to remove
t hanardous air conmmi'm As deGncd by the Bay Area Air Quality Management all new materials for inspection.
District, tdM/
❑Yca Nu
l Mvc aardWx masrialsrtyuimmcnts under Chapmr6.95.fthcCalifor-
niaHcal Sahctypsur.Sections 25505.25533 and 25534.1 undarsund tlutifue Wilding
d ,c nst t it k my responsibility m notify die -upamt of
Aim iebmnsl m r.rwissuancc.ncvuft,,mg�O .4 Signature of Applicant Date
Y / 3 All roof coverings to be Class "B"or better
ancr or authorised agent le