08040137 CITY OF CUPERTINO ms ' s"
AT.O
BUILDING DIVISION PERMIT CONTRC�° R'+INFQRMATIOIV.
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BUILD IbtQ.AOORFS$ORGE DR OPI COMMERCIAL BUILDERS P08040137
1IWSS`�NALMEE: P PERMn ISSUE DATE
ORGE & CUPERTINO LLC 445 LEIGH AVE 05/01/2008
E: SANRARY NO. CONTROL NO.
(408) 377-4800
ARCHITECffENGINEER: BUILDING PERMIT INFO
BLDG ELECT' PLUMB MECH
0 0 0 0
u00 LICENSED CONTRACTOR'S DECLARATION
MF I thereby affirm that 1 am licensed ower provisions;of Chapter 9 aommmeing Job Description
�v`� withseetion7IXIU)ofDivison7ofthc BudM..aw PmfesslovCode,uld mYliccnseis RPLC BEAM
a in full to.and effect.
j License clan tic.9
�, Dau Concr
ARCHf1ECTS DECLARATION
1 understand my plum shall be used as public rtcorde
�yU
L O 5 Licensed professional
s� .] OWNER-BUILDER DE Ce CopurON
0 f 1 hcrtby affirm on I am exempt from the Gonurs;Co c:My c LAW for the
i p O following won. emit d 11171$euaircss and Nofesdons Code:MY city or county
whichresponse;its ua permit re cpwmcl ahec,impose,demolish,or repair say swmum
z prime tlissuance,alsorequires theapplicant tfor hesuchp.rmiuo BkssiLaw suum.m
that he ndog licensed pursuantd70thc provisions of theCBusi ori Ldf=in(CMpter9 Sq.Ft. Floor Area Valuation
(comal me todurpth Serefro.and
th basis f r of .31C,dnev sew PrafAny vs Cndc)or $40
0 0
S $ than on u exempt thrm(rom ant the Per far de ces th d wmpdou.Any l Pena'on of
Semon 7de d by any seed doll for(a permit mbjccu the applicant m a civil Penalty of Number Occu ane Type
oat mart this Ties hundred dalisn(SSW). 31609030 � P Y YP
0 1,as owner of the prep arty,or my employes with wages as their into compensation,
will do the wont and meswnum is not intended e,offered for sale(Sec.RIM,Bum.
and Ptov fessldCode:The contractors License Law does not apply m an owow of Required Inspections
property who build&e,im provesthereon,and who does such work himself or through his
awn employers,provided Sussman improvements sae not intended oroRemd for ole IL
however,the building or Impmamem issold within one year of completion.the CWnv-
builder will have the buNra of proving Shut he did tet build or improv for purpose of
sta).
1.u ownm of tie popery,Sort ucluaia
lY contracting with Bansmcws m
ed con
nstrvm Can Pmjem(Sec.7044.Botinm and professions Cade:)The Commcmrf W-
-ceme Law,does not apply to an owner of property,who builds or Improve theuan.sad
who contracts for such pmjeets with a conuscim(s)licensed pursuant to the Contractors
Lkense Lw.
❑I con cx mpt under ee ,B B.P—C(e,this uaton
TG/�f�-G P ` Dine
W0R�6 MQ_PEN5ATSON DECLARATION
1 hereby Num under penalty of perjury oro of the following dxlarstions:
I have and will maintain a Crnifinte of Covent mself-iiuurt far WoskcesCompen-
onion,as provided for by Sidon 3700 of the Labe,Code.for the Performance of the
work for which this permit is issued.
❑I have and will maintain Workers Compensation Insurance,as required by Section
]71D a(the Labe,Cods.1.the performum of the work for which this permit u issued.
My WahceS Compensation lnsusum carrier and Policy number are:
Carrier: Policy No.:
CERTIFICATE OF EXEMPTION FROM WORKERS
COMPENSATION INSURANCE
(Thissection need not becomPleted if the permit Is(sone hundred dollars(5100)
nr los.)
I ceratify Nat IS We pusfmmance a the work for which this Permit u issued,l shall not
employ say person in arry manrcrm u m bSome subl.ct m lir Wortrn'Comp:vauon ,
Laws of California Date —
AppliCan l
NOTICE TO APPLICANr:IL after malting this 'm f Exemption,you thonld
become subject m the Workers Comp:nsktion. ,Wtuns o the Labor Code,you mail
,J O forthwith comply Wild such Provisions ser this Permit shall he deemed revoked.
z 0 CONSTRUCnON LENDING AGENCY
Thereby aRrm dual them iso emuuucunt lending agency for the pef(osmams of
tY the work for which Nis Permit is issued(Sec 7097,Cih,C.)
Lenders Nun. '
.7 z Lenders Addw
U O 1 Cannily 0-11 have mad thus applicmion and sum this the above information is
W C—CL I.I.m comply with all city and county ordinances and sum laws miming to
.O building construction.and hereby authoda mprexnboiM of this city or enter upon the
oboes-mentionedpmpeny for Inspection purpowhich may
F 0. (We)agree m era,indemnify and keep harmless the City of Cupenme against
IA inconses.quence of lots.
cruandof thisw.twhich mvy in any way accrue against said City
U z A PLICAuee of the R!rTAN of this pcoddL
D WILL
APPLICANT UNDERSTAN✓D�S AND WILL COMPLY WITH ALL NON-POINT Issued by: Dale
SOURCE REGU PO. ='(
o Re-roofs
Sr{nuure ofApphcanUCo tractorRDOU pass
HAZARDOUS MA fALL-01 OSURE Type of Roof
Will 0e&p32 jIuser fMurt building e,uupaptmm orand the
hauNoud Suriai
deRned by tie Cupertino Municipal Cade.Chapter 9.11 sew Ne Heaith and safety
.srstion zss7zp)7 All roofs shall be inspected prior to any roofing material being installed.
❑Yes �l No
j^ If a roof is installed without first obtainingan inspection,I agree to remove
Will the applicut or future building occupant sax equipment or devles which P
I(bvArdov air contaminants u derined by the Bay Area Air Quality Management all new materials for inspection.
D
istrict?
❑Yes )QNo
I have matt the haaasdws maurialsmquhc rse.undo Clupter6.95 of the Califm-
HcalthhSafctyCwo,sxoions155 .25577ow Z5s74.lunduvu ifde building
ns not Currently hew s moist.esu it is my responsibility to notify the tempter of de
uimmcnu which mu met pier m issuanm of a Ccnifeau of(
aCSy 5-771 5C
Signature of Applicant Date
e,antharivedasem Dam All roof coverings to be Class'%¢"or better