04050151 CITY OF CUPERTINO a r.+ 6 I�sF.+ • �k,� : �a N ?
BUILDING DIVISION PERMIT � CONLRACTQR�IIYORMATIOs
BUILDING ADDRESS: ESPRIT DE LA DANSE PERMITND04050151
OWNER'S NAME: PERMUISSUEDATE
ESPRIT DE LA DANSE nr� /2c;/2n04
NE: SANITARY NO. CONTROL NO.
ITECTIENGINEER: BUILDING PERMOANFO
BLDGELECT PLUMB MECH
0 =
u o o LICENSED CONTRACTOR'S DECLARATION
CmF 1 homey arfirm that I me licensed under provisims of Clupmr 9(commencing Job Description
SZ�yf with Salion]IXXp of Divixion Sof the Businesx and Profcssioos Codc,andmyliccnacis �Q[R�II�n �
mm 11.and effort. TI- -DANCE STADIO
h vvj? Licenm cl.. Lk.N
F Dam Contractor AUGARCHIECIS DECLARATION AUU 2004
v�ot I understand my plans shall Wuaed u public recnNa
Dwu
u. Licensed Professional
Z[) OWNER-BUILDER DECLARATION SQI�Qf) ®IL�II.P�
I hcmhy.R'm Net I am excmpl from the Contractors Lkems,law far tine V' IV �tl l�
E a O following mason.(Section 7031.5,Business and Profcssiaos Cade:Any city or county
29 which requites a pmmit m ennswcL alter,improve,demolish.or repair any motion
_Zo prior to its houancc.alm rcquima Neapplicanl forsuch pennilmfim asignedsmement
Nal he is licensed pursuant m the provisions of the Contomoor's License law(Chapmr 9 Sq.Ft. Floor Area Valuation
or 1— (commencing with Section]000)ofDivision 3 of the Business and Pmfeasioos Crum)or
k w§ that a u exempt tlmrefrom and dm basis for to alleged exemption.Any violation of
Session 7031.5 by ansy epplicanl for a permit mubj.cu to appl¢ant u a civil penalty Of 3 kgN33k318er 0 0 Occupancy Type
not mom Nan five hundred dollars(5500).
Cj 1,u owner orthe pmperty,m my employcu with wage m ftk mle compenudon,
will do the work,and la swUlum is not intended aroRewd forsak(See 7044.Business
and Professions COde:The Contraawri Limrsz Law dam au'apply m an done'or -Required Inspections
Own enywha Cents:
imprandwho an
tele himaelrorNmsle hu
Own employees,provided that such imprommeau em not intended or offered for sale.If,
haveer.Me building burden
of prnantiscoldwithinone year of completion,Ne owner-
builder
wned
builder will hall to burden of proving Net W did not Wild or improve for purposes,Of
sok.).
O 1,as Owner of Ne pmpcny am exclusively contracting with licensed contractors;to
construct Ne projen(See.7(114.Business and Professions Cade:)The C murmters Li.
nose law does nos apply u an owes'of property who Wilda or imam.Nemo.,and,
who contracts for each pmjecu with a conexclor(s)licensed pursuant to Ne Convenors
iMy
law.
exc+mpttuunder Sm. l� .B k PC fm Nis moon
�"s/J f v-�1 _ NbA lG Data �t
WORKER5 COMPENSATION DFRLARA to
I hereby affirm under mostly of perjury arc of she fallowing declaruiom:
ve and will maintain s Certificate of Continuo aelf-insure for WOrker'e Comp n.
u provided for by Section 3]00 of to IaW,Cade,rte Nc performance of Bte
r which this permit is issued.
se and will maintain Worker's Compensation Insurance,u requited by Section
0.Iabo,Code,far dm performance or the work for which this permit is issued.
rku's Compmeaation losmatxe carrier and Policy number tie:
Carrier: Policy Na.:
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE '
f Dt is seen on need not occomplem l if tes pe'miHa far one hundred dollars(SIM)
less.)
1 comfy Nm in the'
dormme of the work for which Nma
is Permit is issued.I ll at
employany person in anncr scum Wcome subjeclmsW Workc'i Compensation
tawant Calico is
Applicant s"
NOTICE To
PLICANr:If,arm,making this Certificate of Fsemption,you shouW
become s 1 m Ne Woher's Compensation provisions of tW labor Cade.you mus
Z, forthwith comply with such pmvninm ar this permit shall Wdccmcd revoked.
z O CONSTRUCTION LENDING AGENCY
(~ I hereby affirm that there is a constmctinn lending agency for the performance of
> Ne work for which this permit is Wad(Sec.309],Civ,C.)
W Q Lemm,'.Nam.
6.
i deLenrs Add.
V1 certify Net 1 bate read this application and sum Nat ted mete information u
W (—' Correct.1 agree to comply wish all city and county ordinances and State laws relating to
O V Wilding construction.and hereby authorim mprnentvti.Of this city to enter upon the
}fW above-mentioned pmpeny for iospcedon purposes.
(We-)agree to on,indemnify and kap a'mleu Om City Of Cupertino egaiost
ih liabilities,judSoune.costs and expenses which may In any way accmc against said City _
U Z in cnnxgoe4mo or Nc gmnting of this permit.
r-. APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT Issued by: Date
SOURCE R ULATIONS. t
S` elf Ty roofs
9�ena a ppbcanVZARDO S1tw�
HAZARDOUS MATERIALS DISCLOSUREl Type of Roof
Will dtc applicant or future building occupant.Chremm or and the
haealth and
u defined by the Cupenirm Municipal Cade.Chapter 9.11,end the Health and Safely '
Cade.Satio.15531(a)7 All roofs shall be inspected prior to any roofing material being installed.
O Yes All
lal-: Will the applicant or future building occupant use equipment Or devices which If a roof is installed without first obtaining an inspection,I agree to remove
cr
hr mem a air contaminants u&f,.d by tW Bay Am.Air Quality Management all new materials for inspection.
WL?
❑Yes Nu
1 have maJ the ha,snkms materials requirements underchapmr6.95 of the Califor,
ealth&Safcty Codc.Saumu V5M5.n533am125514.1 understand Kalifdm Wilding
not currently ham a mono that it u my responsibility m notify Bre Oesupanl of the
whlchor la, p.oruissuanccofaccrtificamo"cu2`,Y—amu Signature of Applicant Date
n r ^^ I L /lAll roof coverings to be Class"B" or better
or authodsd agent Ie-