07060023 CITY OF CUPERTINO � . +kr+ + te 'fg "��' i*°
BUILDING DIVISION PERT
F :. `..A-eyT,.rv'�,CRYx0. 3"'w4..A. vaC,vl.Ft6.
BUILDIyG/.pQ3LESS:LORA VISTA AVE TBD — TO BE DETERMINED 07060023
OWNER'S YNA�MEE: P PERMIT ISSUE DATE
MR XIE 04/07/2008
HONE: SANITARY NO. CONTROL NO.
RCHRECT[ENGINEER: BUILDING PERMIT INFO
-BLDG ELECT PLUMB MECH
0 0 0 0
�oo LICENSED CONTRACT'OR'S DECLARATION 7 Job Description
r6 1 hereby M.Nal I am licensed under provision!of Chapter 9(mmmcncin{ P
with Section 70M)of Division 3 of the Business and Professions,Code,and my license u SFDWL-2 STORY..3, 613, GARAGE 599 '
jJ4 Lii«IscOasa eCL Is.0 3/10/08 STARTED WORK W/OUT PERMIT—STOP WORK
Contractor
E Dam ARCHITECI'SDECLARATION ISSUED,DOUBLE FEES PER LARRY.
1 understand my phut shall he used as public records r
J
e tad
Licensed Professional
S m Oat I AM exempt
from
DECe Commodes
at�S I kreby.(Su that 1 1. uempt from the ewntrlmorY i A License Use for the
is O o which re reason.(Sadao co Id,Business and Profcadan Cade:Any city or county
S 9 which requite•permit re construct.alkr,in prow,dcermitt sirrile a sig ed structure
thatWm wItscensedalt r W resthe theapplicantof for c suchCar en's icuse aw(Chmmcm
€< Nukblincirg with Sudan 7000)
of Division
afofdhe Business and
PurlslanxCptm9 Sq.Ft. Floor Area Valuation
$ (eoneesexemttharfentandtebasisofroftkegedcutantion.MktCode)of $450000
dui a h exempt Nertfrom and the bub for tic alleged essmant s Any violation of
Sudan loll Iby any redden for,pcmil abjecs,the applicantm,civil Penalty of e.iyN Number Occupancy Type
trot mom than Bw hundred dollen(530)). 32628079 .'Vt7' P Y YP
❑I,uownerof the property,or my employat wide wam As their sole cwmpetadon,
will do the worlt,nd ax tavclua is mat atuded or MTcmd far We(SecHaw.Bur. Required Inspections
and Professions Code:The Commune!License L a.awes oat apply m an awnar a q P
property who but Ida or improwa thereon,and ww rices ut h work himself w through his
own employees.provided that such improvements,m not intendW ora@red forme If.
however,Ne buildingvah,or Improvement Is as Im diinaroyeu of ceprove(n,theowner- '\)/�\\,— �rW edtt wW dew tiro burden of provingNat k old oat ddW a Improve fon puryote ofTARY
`-\\\\V(Alrale.). rrr"""���
t3 L n awns of Ile property,.B exclusivelydd contrasting with Grouted commissioner .
common tk por such
)Sec.projects
as acent ant Profesdon Code:)The the onmh U-
Law.
resis
Law eau sot app1Y te!n owner of propenY who builds m improves thenxn,sena,
who contracts for tach projees,wide tmnuamon(t)Iiunaa pursuant m the Conuaetors
Lkete exempt
[3 14m exempt undtr See � �^ ,Bd PCfor Nts reawn
Owner I�/�—/�. i Dam��k
ER'S C M SATIP�! ON DECLARATION
1 hereby,Blrre under penalty of perjury ane of the following deumations:
haw and will maintain•CeNOnmaf Consent to self-houre far Worker's Compcn-
n,
,for u provided for by Section 3700 of Ne Labor Code,for the performance of the
-
which this permit is imams. ,
❑I Nw and will maintain Workers Compeu•llon Insurance.u mquired by Section - - -
37M of Ne Mar Cade,for Na performance of the work for which Nis permit is iuued '
My Workers Computation I..Act artier and Polley mania tae:
Cartier. Poliry No.:
CERTIFICATE OF EKEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(This ambos deed not kcwnplemd 0Ne permit b farm hundred Mans(5100)
or leu)
I unify Not in the performance of the work for which this permit ts loved,l shall not
employ any perran in any manner se u m teethe sinbJrset ly Ne Weaken'Compelfidm
Laws of California Data
Applicant
NOTICE TO APPLICANT.If. r m mg Certinnte of Exemption,you Nou1J
become subject to the Worker!Compensation provisions of th.Labor Codc you malt
Q O forthwith comply with such provision or this permit thall be deemm
Accrued ated.
z y CONSTRUCTION LENDING AGENCY
[-w (hereby AM.that Nem lttcoiaouNmn hndingagenry for the perform•touf
ori > the wart for which this permit bended(See.3097,Civ,C.)
It7 0Landers No.
w7. z Landers Address
t.)Q 1 unify that I haw read this application and sate that we aww information Is
t" correct.I•gme to comply with all city and county on inanus and seam laws relating is
building construction,and herebyauNorise mpreanutiwt of this city to enter upon Ne
{57 akw-mentioned property for Inpecdon purposes.
G (We)agree he use.indemnify and keep htrmless the City of Cupertino agunt
N liabilities,Judgmenn,easa and expenses which may in any way accuse against aid City
V 7 in cotachenee of we gnndng of this permit. ,v
�7 APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT Issued by: Date '/
SOURCE REGULATIONS.
: 7 (//7ff r( Re-roofs
are
Siguof ApplicfiNCmarsuer DAM
HAZARDOUS MATERIALS DISCLOSURE Type Of Roof
Will N.applicant or forum wilding acupant store or kndk hatruon mamrisi
As defined by the Cupertino Municipal Cade,Chapter 9.13,and the Health and Safety
Code, r]Y.
No
xss3:(a)+ All roofs shall be inspected prior to any roofing material being installed.
❑Yrs
Will the applicant or future wilding occupant use equipment ser tlevien which If a roof is installed without first obtaining an inspection,I agree to remove
t hmurdnt air commedeme,As defnN by tic Bay Area Air Quality Management all new materials for inspection.
corn
C]yea EfNo
I blue read the huudims muerlW requirements under Chapter 6.95 of the Califor.
nb HUI"Salety Cade,Sections 23305.25533 and 75531.1 nmmnmm thn If ft building
dais Ml conremly have•moat.Nu it is my respotihility m redly,Ile oaupint of the
requirements which muakmel priorpriorm iasices `fl Cenifaaa of Ocu Signature of Applicant Date
Owner Or Uthmiud�agAll roof coverings to be Class'W'or better
Owner or anthmnsd a Dam ^