08080055 CITY OF CUPERTINO
BUILDING DIVISION pEjjiylj'r kC{ONTItACTORIN ',ORMATIsO„3�N�.,
BUILDING ADDRESS: PERMIT NO.
1.0679 GRAPNEL PL EDWARD CONSTRUCTION 08080055
NER'S NAME: PERMIT ISSUE DATE
KOD.1 PYAKA 2533 AMETHYST DR 08/07/2008
PHONE: (408) 985-0731 SANITARY NO. CONTROL NO.
ARCHITECT/ENGINEER:
BUILDING PERMIT INFO
-BLDG ELECT PLUMB MECH
0 0 0 0
�o p LICENSED CONTRACTOR'S DECLARATION Job Description
U 1 bunchy affirm dual 1 sm liRruund
ed er provision of Chapter 9(mmmenim Pc
with Soot, 7000)ofU'v-mo 3 efthe Busireuandi'mfessi Code dmyfrcense4 REPR FNDTN @STMWL @FRNT ENTRY AREA
n a in full Tone ane effect, ly/37
License au Lk.Y /f0 fes—
=� Dow — Contractor
ep .� ARCHITECTS DECLARATION
W U I undersand my plants shall o„•a u public rtcaNs
o.
g tae in LiceveJ Prefessional
3OWNER-BUIUER DECLARATION
nnyy I W." from
that I em exempt from Ne Convacroes License Law for the
`p O following reason.(Sced.7031.5,Business and Professions Date:Any city or count,
Swhich no rims a pc mil to cmuuuc.alas,hnproe,demolish.ar repair any swctum
_Zs< prior at its issue=.elan nalumo dC applicant forbuch permit to file a signed statement
F� that he la reeved
pursuant to the previsions of the Convectors Liecnse Law(Chop=9 Sq.Ft. Floor Area Valuation
a (cornmcmm{wits Secdon 7000)of Div mm 3.f ft Bunneuand Prefeuiov Cade)or $6500
that he 4 exempt theefined and Use has4 for the alk{cd compiler.As,violator of
Suedon 7011.5 by cry applicant for a pmmftsubjects Om applicam 1..civil penalty ofNumber Occupancy Type
not mart dun fist hundred dollars(1500). 3 2 6 4 3 0 5 0 .'UtT'
❑I,u owner of tits Poperty tore,employees w'eh mgr uthe'vek cempewdon,
will da Professions
and the he Corisnarmundedm Law duce,
(Sec.7066.Bud"•o•
and m,.h lou Cade:The Canuaclara License law don rot apply lf t owmr is Required Inspections
man enywhobuiirsorirepmw.s hImprandwho aresoutswork Mrafreilthr We.
ownemployer,preNea, that such impmwmems artnot immndomaQerW for sale.R.
hommWilder.Ne buildingteea,impmveio nn4sald within of )ear of c prem:for
de osteo-
Wilder will haw du buNus of preHng that k ilia not buim o impvw fm puryoa of
tile.).
I,as owner of the property am cclust cmhuting with licensed mnuacmna m
mnstrem the,project(Sec.7044,Business and Preresdons Cade:)The Contractors U.
camLaw don not apply to an owner of propery who builds or improves demon.and.
wet convects for such pmjccu with amnuactor(s)licensed panaceas to tim Conuanars
License Law.
I am cceept under Sec. ,B&P C for this round
Dam
WORKER'S COMPENSATION DECLARATION
I hereby affirm under Penalty of pedury me of the,following 0ec4radorw
u5 hsm and will maintain a CurdOem of Conant to self-ivumfmWorkers Compen-
on.as prrrvided for by Section 5700 of thc Labor Code.for the performan¢of th
wart for which this permit 4 issurd. '
❑1 haw and will maintain Workers Comp rusaimn Insurance,as rmuired by Suction
37W of de Labor Code.for the arfmman¢ofthe work fmwhich th4 perp t4 issued '
My Workcra Compensation Ins urana curie and Policy number are
Carrier. P.lic,No.:
CERTIFICATE OF EXEMPTION MOM WORKERS
COMPENSATION INSURANCE
(TTitsettim need nmbcconpleted if de Pamir 4 foram hontheddndan(SIOG)
or lest)
I certify,that in d,performance of thc work for which this petmis is issued.1 shall not
employ anyperson in any manrmTso�m 2rrjgrybjcnmde Warken'Compewslm
Lawa of uhromia Qom�SCv 3r
Applicant //
NOTICE TO APPLI�C�:If,after making this Certificate of Exemption,you Amid
become subject m the Worhars Cmnpenudon provinans of the:Labor Code,you must
,J z forthwith comply with tech provisions or this permit shall bu decreed Rvnkcd.
?I CONSTRUCTION LENDING AGENCY
[-. 1 hereby alTma dm dere is a constructs.lending agmtoy for the perfomvnce of
0.! the work for which this permit 4 issued(Sec.5097.Civ.C.)
GQ Lenders Name
Q z lenders Address
()Q I comfir that I haw Rad this application and some dal the hose information 4
uL E coma.l agree to comply with"'city
send county mum-ca"and fwd Ian relating m -
Q building,crosuucdon,and hereby audition mpmantadws ofthis city to crur upon the
L57 move-mentioned properly for inspection Purposes
F gy (We)agrec to atm indemnify and keep heueLess the City of Cupcnim against
rq liabilitiqjudgments.costs and ee,uvc which may in any my aeons,against and City
C)Z in consequence of the go ntir{of this Perrot,
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT Issued by: Date 1
SOU!%REGU)STIONS. '• ZJ
/ -N-ars Re-roofs
5i{w ' ,Itrardoizoiuncmr, Net,
HAZARDOUS MATERIALS DISCLOSURE Type of Roof
Will the applicant or forum building acupmsnum orhandlc huerdous mamnal
U defined by the Cupertino Municipal Code.Chapter 9.11-and tip Health and Safety
use.Section 15551()+ All roofs shall be inspected nor to an roofing material being installed.0
Will me applicant or future Wilding occupant me equipment or devices which If a roof is installed without first obtaining an inspection,I agree to remove
emh he haus air com minants u defined by the Bay Amo Air Quality Manegcmcns all new materials for inspection.
Dimict7 P
oyes 2<
I haw Rad de huudoumamna4Rquimosod,under Chapmr6.95 of the Califor-
niaHdd&SofuyCo .Sxvmu15505,25531and25534.IuMcnm ifdc building
does,not co entry he.a tenant,du it 4 my responsibility to notify the occupom of the
regvimmcntswhkh�mst m ipnortoissuaeccofacm rlcamofD up . Signature of Applicant Date
/�rsw-�_ -g-?Da All roof coverings to be Class'fW'or better
Owner o ansd agent . Dam' '