08050171CITY OF CUPERTINO
K,CONTRACTORIATF®RMTI®N
BUILDING DIVISION PERMIT
R-w. 4`19x, `°aM¢i. ^A F•'i� U 'SFcd4SR°
BUILDITj�A TTINCH AVE
lR''�S
TBD - TO BE DETERMINED
�td+ t�vIqq,,
PERU8VS 0171
NAME:
PERMIT ISSUE DATE
.LLISA JORDAN
09/05/2008
P NE:
SANITARY NO. CONTROL NO.
ARCN7TECtfE1JGINEER:
ADD 1036'-3
BUILDING PERMITPLUMB
BLDG ELECTMECH
LICENSED CONTRACTOR DECLARATION
Job Description
horoby rte Wt1. II¢m nder provisions C
'-""", ••"��"^ ^' ^' ^^
erimas andProf
Code, add my licenLi I.
with Section 70110)ect, cion 3ofNe costo. and Profcatiom Code, mtl myliccme in
7")
in full tome etb erca.
Un. un
DowClw
D
Dao: Con
DELL
ARCHITECTS DECLARATION
1 undersand my plate Mall W teed as Public mcorda
Licensed Pmmumnd
OWNER-BUILDER DECLARATION
I hereby all. Nal 1 am exempt from the Contramorm Ucenue Law for IW
following match. (Section 70313. Businns and Professions Cate: Any city Or county
which requites A Permit to comwc. Owl. improve, demolish, or repair shy surnew.
Prior W its issuance, also requires the applicant for such permit on file a signed statement
that he isliccmLd museum m the provisions Of due Contractor, U.. U. (Chapter 9
Sq. Ft. Floor Area Valuation
wo dna eyeing with Section 71)(p) Of Division 3 of the B.Omma sM Pmfeaiom Code) Or
that he u exempt tlerefrmo and the basis for Can allotted csempdon. Any violation of
second 70313 by any applicant for a permit mbjecu we applicant to a civil penalty Of
APN Number
Occupancy Type
rot mare than fsw hundred dill. ISM
❑ Luawhas of Ne pmperty,mmy wplayem wird vngmuthe'v role campewti.,
will onion work. and the structure In notimar ded m Offemd Iarsaw (Sec.70N, Busnw
and Professions Code: The Conmctnrs Lianw law don rot apply W an owner Of
_ Required Inspections
property who Wildamimpmws Jcmn,urd windoesmch work Wonalfm through this
Own employen, pmA&d that such impmwnwon are not intended or offered for sale If.
lawewr. we Wilding or kmpwmem a sold withi OK year Of completion. Ne awme.
Wilda will law Nc burden of pmHng that k did mu Wild or improve for purpose Of
saw.)./
04. - avnm of the property am mdusiwlY contracting with Bcemed conuaaors W
.mtmct IW project (Sec. 7044. Batman and Ped enume, Code:) The Contram is U.
Comm law does rot apply to an Owner a paopeny who Wilds or impmwm thereon anll.
who cot racy for cah pwjects wird a emuracmKa) licensed pursuant to, the Ct nuamm'a
-'
Lienee Taw.
1. m.5'"Oder Sm. BdPCfm rtatco
r %/! Data O
WORKER'S COMPENSATION DECLARATION
1 hueby affirm under penalty of pmjmy had of the folWwing dalartakaw
❑ haw oM will maintain ofCownUo for
37
cancer. provided fear a tion 0 ode. fort
performance:
Section 3'!00 a( the Labor Code. for the penomume O( the
of the
kf r
work far which this permits iaOel
mi
❑ 1 haw and will maintain Workers Comprnsation Insmma, u required by Second
3700nfthe Labm Codo, for the performancemthe work fmwhich Nis permit in iauwnL
'
My Worker. Compewti. Wmrance tuna and Policy dumber tae:
Cartier. Policy No.:
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(This aced. hand .t W complewd iftle permit is furnace imminent doll. f$lW)
m Inc)
I atify that in the pmimmarcn of the work for which Nin Permit in um cd. 1 Mall that
employ airy perm. in any mmrcrso.Ls bWa.m )cot to to Wmhin' Comprnuo.
Iowa of Califo^yL D 0' / L , �
Applicant /'s
NOTICE TO APPLICANT: If, afar making Nu ConiBcae of Esemm mo. you M.W
become subfen an the Workers CanPewtion pnovisom of the labor Code. you Chun
_
forthwith comply with inch provianm or Nis le mii shill W deemed mwked.
CONSTRUCTION LENDING AGENCY
1 wmbY Oman that there is a comwction vending agany fm the perfo.men of
the work for which this permit It as.d (Sec. 3097, Civ. C.)
Lendors Name
Lenders Address
I certify that 1 haw read thia application and main that the Ilona information in
cones I Agree m comply wird ill city and county OMwuem and man, laws relating he
Wilding coosuudetion, and hereby auNmire mpmxnuovec of Na city w enm upon the
abow-mehtiohad pmpcny for inpectl. purpneL
(We) Agree to Saw, Indemnify Nd keep CMllw the City of Cupertino all
IiabiliddL Judgments. coca and eap.sm which may In any way same agaiw.uid City
in easequ een, Of the granting of this permit,
APPLICANT UNDERSTANDS AND WILL COMPLY WI'TI3 ALL NON-POINT
SOSOURCEREEPyULATlIO!NS.
Issued by: Date
Z .WAlk4�
Re-roofs
eugwurc Of Applican,COmfwler
Dao
HAZARDOUS MATERIALS DISCLOSURE
Type of Roof
Will the applicant or future Wilding mcupmsnore or IuMW heardoa maonriil
u deRrcd by the Cupertino Mu kmal Code. Chapter 9.It and the Health and Safety
. 0 Ym .7ss3zc,)? 6,� -
All roofs shall be inspected prior to any roofing material being installed.
Will Na applicant or future Wilding acupnl u¢ equipment or dcvias which
If a roof is installed without first obtaining an inspection, I agree to remove
emit hvardnm Of ronuminmts as defined by NC Bay Arta Air Quality Management
District?
all new materials for inspection.
❑Yes —/
I haw read the huardtuamaeriala requimmc rChepWr G93ofJe Wilding
5534.1
andwildlR1 undcraWamitftwewd eNe Wilding
ria het CturneAdY
Seedwroanhat it
dons rot currtnh how
SAdY haw that it a
9
I myn5533
a cote. my respomibilitY a .tify Ne accupnt of Ne
require= nwnmted had oraiaeanaof. Of«Lupuuy.
Signature of Applicant Date
All roof coverings to be Class'R" or better
OwnermmtWn.dlgLm Dale