06030065 CITY OF CUPERTINO ,g+�,�k5�y'rr�{. 3k,{ 1x �T1�T'
BUILDING DIVISION PERMIT LrVl\=1 4 IZ INF R ATIUN�
BUILDING ADDRESS: PERMIT NO.
06030065
O NAhXE:kiUUU1& CT PERMIT ISSUE DATE
E: SANITARY N L N0.
ARCHrrECTIENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MnECH
t� e I
5 - LICENSED CONTRACTORS DECLARATION Job Description
1 hereby affirm that 1 am Ismsed under provision of Chapter 9(mmmmen{
with Section 70X1 ofD vlalon 3 of the Buskin,and Prokuimu Code.and my license h '
In ren fame and eR g Z y 3 Z 4(,
i� pen 1.'° — c�"aNr REPLACE (E) LIGHTING-NEW PLUMBING FIXTURES
t -
ARCHITECTS DECLARATION CAN LIGHTS/OUTLETS/SWITCHES
? lunderstand myplans Ail]leused upublic recadn ARENA CONSTRUCTION PD FOR BUS LIC 3/13/06
4
i Licensed Pmfcuion.l
OWNER-BUILDER DECLARATION
F 1 hereby affirm that I am exempt from the Contractor,License Law for the
t O following mason.(Section 70313.Buainces and Profession Code:Any city or county
3 which requires a permit to construct,arm,,Improve.demolish.a repair any structure
;K+ prior m its Women,alae requires the applicant for such permit to rile a signed slalement
vac that be islimnsedpunununthe provisionofAnContractor,Licence Law(Chapter 9 Sq.Ft.Floor Area Valuation
-� (commencing with Section 7000)of Division 3 of the Business and Profession Code)or
i$ that he Is exempt therefrom and the basis for the alleged eaempdon.Any violation of
Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of APN Number Occupant e
not nae than ftw hundred dollars($5001
❑1,as owner of Ne property.or my employees with wags as Bmirmle mmpenation,
will do the work.and%e structure Is notinumded motioned faaale(See 7061,Business Required Inspections
and Profession Code:The Comatose.Limns = m taw dnot apply an ower of 31624040 . 0 0 q p
properly who builds or impmw,theren.and who d=such work himself or through his
own employes,provided thatsuch impm nommISsee notlmended creamed funk.If,
however,the building a improvement is sold within one year of completion.the owner.
biller will haw the burden of proving Dat he did not build or improve for purpose of
build.
❑1,as owner of the property.am exclusively contracting with licensed menuaaon to
construct the pmject(Sec.7044,Business and Profession Code:)The Carmichael Li-
move taw does not apply to as owner,of property who builds orimprovn thereon,and
who contracts for such projects with acanvacmr(G licensed pursuant to the Contrctors
License(ave.
❑1 am exempt undo Sec. .B&P C for this moon '
Data
WORKERS COMPENSATION DECLARATION
1 hereby alarm under penny of perjury am of the fallowing decWati vac
I has and will nodws Isc.mOnte of Consent to ulf-Wure for Workers Comper, /
salon,ss provided for by Sadao 3700 0(the labs Cade.for the performance of the
work(a which this permit ts intend.
❑1 have and will maintain Worker's COmpneisuom Insurance,u required by Section
3700 of the Isbm Code,for Ne performance of the work for which this permit is insued.
My Workefa Compenatie Infuses,carrier sed Policy number am:
Cartier. S1'ti�"E (•,s..i Policy No.: t S—I� t�f1— DS
CERTIFICATE OF EXEMPTION FROM WORKERS '
COMPENSATION INSURANCE
(Tint section mood et a completed if the Permit is froom hundred dollars(1100)
or leu)
1 comfy that in the performanm of the work for which this permit u issued,I"I not
employ any person In my manner an as to become subject the Workerf Compensation
Laws of California.Data:
Applicant
NOTICE TO APPLICANT:If.sfw making this Omiricate of Exemption.you should
become subject to the Workers Compensation provis an of the Labe Code,you most
O forthwith comply with such pmvision or this Permit shall be deemed revoked.
CONSMUC ION LENDING AGENCY
I hereby affirm Dat them is a convection lending agency fa the Performance of
the work for which this permit Is Wood(Sec.3097.Civ.C.)
QLenders Name
z LamdcA Add.
C 1 comfy Net I his.read this application W sum that the An.informal.to
fcava 1 agree to comply with all city and county ordinances;and tam It"relating to
IJ building commuction.and hereby mNorim representatives of Nu city to enter upon the
alcove-mentioned pmpeny fa inspection purposes.W
W (We)egret In save•indemnify and kap humless the City of Cuper ino.Pint
y liabilities,judgments.cats son expenxes which may in my soy amu,against aid City ��aa
Z in eoatwgmna of An gr.eng of this permit.
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT Issued by: Date U
E REGULATIONS.
_tZ—a b
RMCRe-roofs
len of ApplicaroConbuoor Data
HAZARDOUS MATERIALS DISCLOSURE Type of Roof
l the applicant or future building occupant hire or W n lk bma dose material
judk,lmd'by the Corinne Municipal Cork,Chapter 9.12,Ind thp Health and Safety
tion 25532(.)? All roofs shall be inspected prior to any roofing material being installed.
Yu �No
ll the applicant or future building Occupant use equipment or dove=which If a roof is installed without first obtaining an inspection,I agree to remove
man fill oentsminants u de0ned by tint Bay A.Air Quality Management all new materials for inspection.
�}.f�Yu k.
I ban mal the huaWmsmmdaisrequimnenuunder Chapmr6.95 of Ne Califor-
ntsHeahh&SafetyCode,Satiats25505,25533am125534.1 undeawb Nrtlrthe building
does et currently law a tone that it h my nes onsibility to edify tint oaupset of the
7nawh.cbmuabcmapdorwissumaofa Ccni amoroccupmcy Signature of Applicant Date
O rota orimdapro Dam All roof coverings to be Class°$"or better