01050178 CITY OF CUPERTINO
BUILDING DIVISION PERMIT CONTRACTOR INFORMATION:
BUILDING ADDRESS: PERM1'r NO.
101050178
OWNER'S KA :. APPLICATION SUB DATE
. 05/24/2001 :
HONE'. - - - _ SANITARY NO. CONTROL NO,
o n.0 C ARCHITECUENGINEER: BUILDING PERMIT INFO
ce ad r BLDG ELECT PLUMB MECH
P i w
sat
LICENSED CONTRACIORS DECLARATION lob DESC(Ipllon
C ✓ Ihereby.Bi.pen.1ad,licensed underprovisionsof Chapter9(commencing -
F,rntw with fall fon7Wpl effect, on3Mthe Basiness and Pmfosions Gee,anA mylicenw
oaLirmron lass aenb<L «DEC! :�
z ¢ hi¢nsc Class. Lic,b
Dare Contractor
ARCHITBCr'S DECLARATION
F y O g 1 undemund my plans slmll be used as public roand, 2/
d}-
-se O LiccnaA Professiunul
o a OWNER-BUILDT:R UIiC1.ARA'1'ION
to 1 hereby ztlirm that 1 am exempt from the Contractor os s:Any c ty o county
of Z following massa(Section 7831.5,Foxiness and vet demolish.
Code:Any city or county
ce whim requires.Penni,re l a es lie after,improve,demolish, file
scrota any swmurc
w3m fifialprinnns Iscranm,aboreyuin%Iheuprinofor such pelo,,Li lcas. .igmJ orniernt
(commescingstal oithSction700)of isionannbftheBuames anenselawonsCaY Sq. Ft. Floor Area Valuation
(commencing with Section om and
Division 3 of the Business and Professions Cade)
or thathe7 exempt therefrom and the basis for the alleged exemption.Any violation
of Sectiod,o31 5 by any officiallh...( pemnit subjects the applicanno a civil penalp
—TJon/t rm,remattfive hndreddnur,rn(a5on). � � APN Number - ' Occupancy Type
fJT.i,ow rof the property,or my employees w.In wase•m their ole compensation. L-A .
will do the work.and the structure is not Inmmlal or o@red for rale(Sec.7BLI. �+
Bonne•%and Professions Cale: For Comment's License law doer not apply to an Required Inspections
owner of prnpeny Who builds or improves twhim
hereon,and who doc% ch work self
tiongh his nwn.,nplayre..pmnldal that enc,improvements are not intended or 1 Err. —'.F'L•NAI,,.�8U I I_la+I,NC-�.t
offered Ins sale.IT nowever.the wilding or improvement is rale within ane year of '5!.• _ , .
completion.the caner-builder will have one burden of proving that he did not build or -
improve for pn,ry,w of rale).
❑1.as owner ill IIto pmpen,urn cxela,"el.canm<fing with rtenrcd n,mmcmix to .
mnruct the project(Sec.9(94.Business and Profmsion%Cade:)The Contractor's
License Law does net apply to an owner of properly who builds or improver Neeson.
and who contracts for such projects with a contractor(%)licensed pursuant to the
Conoids ,Liceme Law.
❑lam aecm4fid.
B&P .,,,his rcation .
Uwne
Imad ,h f f,he 5a Iowa. declarationspont rn palmy onus g •
r] 1 have and will maintain a Certificate of Consent to self-insure for Workers s
Compensation, m provided for by Section 37M of the labor G,Je, for the
rerfonmince of the work for which this permit is inure.
❑I l nv<und will manalue Worker's COngwnwnlon humane,,as required by Section
370X1 of the Wnnr Code,for the Performance of the work for which this permit I% _
.sued.My N0r4r's Compensation Insurance carrier and Policy number arc:
Carrier: Policy No
CER9 I19CATION 017 BXFM 1111 ON FROM WORKERS'
COMPENSATION INSURANCE
(This rection need not W completed ilia,pemtit is lin one hundred dollars -
(51(X)or less.)
I cenily Nm In the pufnnnance OI lie work for which this permit is issued,I
shall not employ any pawn in any manner so tax to become wbjm to the Workers'
Compensation taws of Coltman..Date
Applicant ,
NO]ICE'10 APPLICANT:IL ul,cr Taking this CcniGc'alc of Excmpoe".you'Mould
become subject to Inc Worker's Compensation provum mof the Labor Code,you must
Z Q forthwith comply with such provisions or this permit shall Be deemed rovked. S
F ti CONSTRUCTION LENDING AGENCY
a 7 hereby v0inn that there is it mtntmctlon lending agency for Ilse go:kernance
W of the work far whirl, his Pani,.1 issued(See.3097,Ci,C.)
Q Lender's Name
= z u.acs's Address
U0 1 cenily that I hove rani,...npplicalum and%tam Ihto the obovc inlbnnmio i In
[r a ncd.I agree m comply with all city and enr,rny ordinances and state lases relining
t.7 a,building romoraction,and hereby carbonic rcpre%cra vcs of this city to enter upon
y the aMwe-mentioned property for inspection purposes.
F 6, fWe)agree to save,indemnify and keep harmless the City of Cement ino agai nw
t/J liabilities,hadgmemv,costs and expenses which nwy in any way accrue against said
U z '
City in n,nseyucme of gmntrns of Ihi m t.
APPLICAM1T UN ERS'ANDS ANU t COMPLY WITH ALL ON-PO' T
s, n ' . 'ti�T c! Q� Issued by: - Date
.-g ta��T_ ppneart a a<ar )are Re-roofs
HA'. i[ US MATERIALS DISCLQ41 E -
w p Ne applicant a lune w'ad'ing><<ttpem nos or nandm n-Silas r matedw Type of Roof
a%defined by the Cupcninn Municipal Cale.Chapter 9.12,and the Health and Safety
Cale.Section 532(u)?
0Ye` CNo All roofs shall be inspected prior to any roofing material being installed.
Will the aprrp ntnrmmrewildtngne<up nn cptuipmemnrdcri which If a roof is installed without first obtainin an ins ection, 1 ree to remove
emit hara dour airy moon enu as defined by the Bay Area Air Quality Management g P a g}�
District? all new materials for inspection.. Applicant Meant understands and will comply with
0YCt, 0 N all non-point source regulations.
1 bale read the lo-dolour nomenvl,requirements under Chapter 6.95 of she
Calirarfix Health&Stably Calc,Sections 25505.25533 and 25534.I understand that
if the building des not current])have a mann,that it is my /,.fy thecupam of the rtyuirt a t. x'hi m.vt be ran prior mirsuan eOI'a iec Signature of ApplicantDate
1 a it All roof coverings to be Class "B"or better
OFFICE