05110115 CI'T'Y OF CUPERTINO fi�a77-777777-77777,77, 7,
Run.nwc ulvlsloN P);RMIT zCLTNTRACTpR TNTURMATTON3:.
B UODING ADDRESS: DPM PROPERTY MANAGEMENT, ��MIT No.05110115
1607. S DF ANSA BT,ViJ
OWNER'S NAME: FERMrr EBUEDATE
DOLL7:NGER DE ANZA ASSO.T.CATPS555 TWIN DOLPHIN DR 12/06/2005
SANITARY NO. CONTROL N0.
(650) 508-8666
ARCHITECIE.NGINEER: BUILDING PERMIT INFO
BLDG ELECr PLUMB MECH
�Oo LICENSED CONTRACTOR'S DECLARATION
xg r C I rarely
afrrm dmI 1 run licensed under provisions of ChaP¢r 9(commencing .lob Description,n ry
r�Hwith Sccl co ma 1AfecDivision Sof the❑usincn ane ErOfess��e��of my nsc is J // ,1 /
a in full tn.cc ane effect. C�/J/eVy TI--2 OFF'.T.CES/SHIFT WALT S/DEMIUD
Z Liccnu Class LIc.M V
HO Date Carl racmr
ARCHITECTS DECLARATION //;;
�or Inndcrsmnd my plans shall he usere
d as public cords (/1+/A
o. t
t
'0h Licensed Professional 9n
OWNER-BUILDER DECLARATION Lf/0
<I I hcrehy affirm that I um cxempl Tram the Cama License Law for the
❑O following mosno.(Section 71131.5,Business and Pinfcssinns Code:Any ally nr county //f //r0/ ?,i(�
5$ which¢quires a Permit m consonant,alter,Improve,demnlish,or tupair any structure �` (( // f , ,) 2 0 6 2 6 3
pdor to its issuanre,also terluires the applicant for such Permit m File a signed staRm,nl
Ihar he is licmtsed porsuanun the prin,monsof the Conlrncmr's Litems Law(Chapter 9 Sq.Ft. Floor Area Ud 'Whiation
yF$ (cum mv.oche,with Search 7r(IB)of Division 3 of the Business and Professions Cndc)ur l \\
y .. hm he is exempt shemfrnm and the basis for the alleged exemption.Any=Of
Section 7031.5 by any applicant for a Permit subjecu the applicant to a civil Penalty of A fig R;VWFT U Occupancy Type
mol mare Nan five hundred dollars(S500).
El I,as owner of tle proper y,or my emplayco with wages as their salt compensation,
will dothework,and the hs Contractor's
oncroti Licensmoffered Tonle(Sec.too 44,Business
and ertywnoh Code:The improves
e,License Law goes not apply lf an owner of Required Inspections
pveranywhoe,.or thin suchemon,and
emaerdoes such work himself or through his
own employes,ProvidedNm suchimprovementsarenetintendedormBered forsale. r.
however,the have
or improvement is h to within one year of completion,the owncry
builder will Lave she burden of proving that he did not build or improve for purpou of
sale.).
❑Las owner of the prnpeny,am exclusively cnntracting with licensed contractors to
construct the project(Sec.7044,Business and Professions Code:)The Contractor's Li-
cense Law does not apply to an owner of property who builds or improves thereon,and
who connects for such ferrous with a commetor(s)licensed pursuant to the Contractor's
License law.
❑l am exempt under Sec. ,B&P C for Nis moon
Owner Date
WORKER'S COMPENSATION DECLARATION
1 hereby olfum under penalty of perjury one of the following declarations:
rave and will maintain a Certificate of Consent to self-insure for Worker's Compere
n,as provided for by Section 3700 of the labor Code,for the padho m on,of the
work for which Nis Prmil is issued.
❑ 1 have and will maintain Worker's Compensation Insurance,as required by Section
37110 of the Labor Code,for We performane/e of the work for which this p.it is issued.
hayierrker's:sa LPEM lryurance carr'er and Policy number am:
Carder. AL,f Jn r EE,.riyL I'nlicy Nn.:MJ,�0�aK7�—j,
CERTIPIC TC Of GKEMPr10N PRO W I( ERS'
COMPENSATION INSURANCE
(This statin.neral ml he completed If the permit is forme,hundred dollars(SIRB
or less.
I certify that in the perfmmanee of the work for whits his permit is issued.I shall not
sm play any person in any manner so as to become subject to the Workers'Compensation
Laws of California.Date
Applicant
NOTICE TO APPLICANT.IL after making this Certificate of Exemption,you should
become subject to the Worker's Compensation previsions of the Labor Code,you must
z forthwith comply with such provisions or this permit shall he deemed revoked.
'y O CONSTRUCTION LENDING AGENCY
[r Ihereby.affirm that there is a construction lending agency lot the performance or
CLQ the work for which this permit is issued(Sec.3097,Civ.C.1
W Q lander's Name
xa7- z Lender's Address
U C I certify that 1 have read Ibis application and state that Ne above information is
I4 (~ correct.1 agree to comply with all city and county ordinances and slate laws relating to
C building construction,and hereby vuthorim representatives of this city to enter upon the
JUJU above-mnntinn,d intercity for maturation purposes.
gy (We)agree In save,indemnify and keep harmless Ne City of Cori against
rn liabilities,JJ'ndgmc sts and expenses which may in anyway accrue against=to City
V z in conuTucmccof tha ming of this permit.
r. PIfLICANT UNDERSTAND ND WILL COMPLY WITH ALL NON-POINT Issued by: Date
� 0 NS.
s Re-roofs
Sl,rtum fAinploomuccomacour Dam
HAZARDOUS MATERIALS DISCLOSUR. Type of Roof
Will the applicant car fuwrc building oeeupam stem or hanJlc hararduus material
as defined by the Caperton Municipal Code.Chapter 9.12,and the Health and Safety
ade,S 12"25532(an All roofs shall be inspected prior to an roofing material beim
❑vee ❑ P P � Y g g installed.
Will the applicant or future building occupant use cgolorro t or devices which If a roof is installed without first obtaining an inspection,I agree to remove
ha[mines air contaminants as defined by the Bay Area Air Quality Management all new materials for inspection.
❑Yes o
,l have rcadthch Mous materials requirements under Chapter 6.95ofthe Cal lfor,
data can amor,fmysh c.Sucdonshot it is re, and2553A.1 to enjo rad that ifap., (ding
/ Jno not curtemtghasm n P.nanl.Nm is is my responsibilily ha nndly the xnrpanh of rbc
i` loornrentS�wld,MIIIOSI' mel mnnissusnccoisCMificatcof spam / Signature of Applicant Date
o nor m arnhnd,ed ager, o> All roof coverings to be Class"B"or better G