05110012 J
Y OF CUPERTINOUILDING DIVISION PERMIT C INTRXCTOR�TNFORK , f0 r
"NG ADDRESS: PERMIT NO.OS11OO12
640 HOMESTEAD ROAD'S NAME: PERMIT ISSUE DATE
MICHAELS STORES INC 0 31 2006
: SANITARY NO. CONTROL NO.
ARCHITEC(ENGINEER: BUILDING PERMIT INFO
BLDGO ELECTO PLUMB
MECHO
3Op LICENSED CONTRACTOR'S DECLARATION
d 1 hereby affirm dim 1 Am licensed under provisions of Chapter 9(commencing Job Description
IN Sudan TORO)of DiAsmh 3.1'the Budnweand Pro(wduw Code,and my license Is
^Zt infullforteandcff T. I . FIRE RISER TO BE RELOCATED
I Licence Clue Lk.tl tO 7 3 R �
3g Dam contranmr I. 073,Yr-'T T-BAR/MECH/ELECT/PLBG
ARCHITECTS DECLARATION �—
u 1 urummand my plane Mall W used As public records
k Licensed Professional
OWNER-BUILDER DECLARATION
1 hereby atM m that I Am exempt from the Cantradrs License law for the
D O following mason.(Sedan 7031.5,Business and Prefwsimu Cade:My city or county
$ which requires a permit to construct,that,Improve,demolkh,ser repair any structure
prior to its issuence.alm requires the applicant for each lmrmit to file A signed wtement
qQF<
tom le,is licensed pursuant in the provisions of the Conuazmrl LJanm Law(chapter 9 Sq.Ft.Floor Area Val 113Hr1000
3� (commencing with Section 70010)of Division 3 of Lee Business And Professions Cade)or
jt thus he is asempt therefrom and IM basis fm the alleged exemption Any violation of
Secdon 7031.5 by any,applicant for a permit objects the applicator in a civil penalty ofy��p�N ql�ober Occupancy Type
arc N
nor man five hundred dollars($5001 3 L 61.V LJ S 7 . 00
0 1,As mvner of the property,or my employees with wages a their ole compeneadon,
will do Ilse wok,and the stannum is rear intended or offered for rale(See.7044,Bealrcb
and Professions Code:The Commerce,Lmmum Law dew not apply m an owner of Required Inspections
propenywho builds or imprnvea thereon.and whoduasahwork him elfor Waugh his
ownemployces.provided thmaah improvements art not Intended reoffered frebta.If.
however,Ne Wilding or improvement it old within one Sear of completion•the builder
will have the burden of proving that he did not Wild or improve for purpose of
buil.).
❑1,As owner of the properly,am exclusively contracting with Iicera d contractors in
construct the proJen(Sac.7444,Bmkese and Profession,Cade:)The Contromrs LI•
ceuse law does not apply m an owner of pwpeny.wbo Wilds or improvm descent.and,
who coronets for such projema with aeonmacmr(q licensed Dunwm to the Conuaemra
License Law.
mwemptunder See ,BRPCforthismaon
I Dam
WORKER'S COMPENSATION DECLARATION /
I Mosby drum under penalty of perjury ore of the following declared.. �( O
❑[ham and will maintain aCeNficate donations An self-insumforWorkeraCompen-
sadon.As,provided for by Section 3700 of the Labor Coda.for the performance of IN, y
work for which this permit k issued.
❑I have and will maintain Workers Compensation Insurance,As required by Scdon
3700 of the later Cadc,fes the performaweaf the wok(mrwhich this permit Is Ln,,wd
My Workers Compensation Wee
ion s ncarrier and Policy number atm:
Carrier. { Policy No.:
CERfi' OF EXEMPTION FROM WORKERS
COMPENSATION INSURANCE
(This recdon reed not x completed ifthe permit Is fararm hundred dolmen(SIOO)
or lest) •
I ceNfy that In the performanm of to work for which this Permit Is Issued,I shall not '
employ any person In sny�menner eob)o baamr�subject m the Woken'Compewdw
Uwe 01 Ctli(aam Bsm www\ n
Applicant t t�l,ws
NOTICE TO APPLICANT:If,After making this Certificate of Exemption,you shouW
bwn0e Numt m NC WO tem s Compenbfi0n provisions Of the Later Cade,you a=
O O forthwith comply with men provisions or this permit shallm
x deeed revoked.
,'Zy CONSTRUCTION LENDING AGENCY
(•+ice+ I hereby atRirm Nat Nem it a construction kndingagemy for the performance of
ai n�.r the work for which this Permit Is issued(Sec.3097,Civ.C.)
GQ Landers Name
=z IaMers Mdreb
U Q 1 certify that 1 have read this application and state dor the above information is
U.!". ererect I Agra m empty with all city and county ordinances and mem laws totaling to
Q SV" Wilding construction,and hereby euthoria representatives f this city to enter upon the
W ebove•mcminwd property for Inspection purpww.
pkr (We)agree to save,indemnify and kap hermkss the City of Cupertino against
(4 IhbllitictjudgmenW come and expenses which may in anywayammeagaiwrseid City
V 7 A PLICA T NDER TAN of this permit.
T=7 APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT Issued by:-S Date
SOUR EQ LATIp�`+S.
A-=-- )'-�1— r) fn Re-roofs
Signature of AppliwndConwcbr Date
HAZARDOUS MATERIALS DISCLOSURE Type of Roof
Will the applicant or future building wcupactsmrc or handle harandous material
fined by the Cupertino Municipal Code.Chapter 9.I2.and the Health and Safety
Sudan t�No
ezss3255320)? All roofs shall be inspected prior to any roofing material being installed.
E]Yet
Will the applicant or future Wilding occupant use equipment or devices which If a roof is installed without first obtaining an inspection,I agree to remove
mh ha'rafdous air contaminants u defined by the Bay Area Air Quality Management all new materials for inspection.
Dlalrict7
❑Yea eNo
11haveroad theh Aa ..materialsmquimmenuunder ,Chapter Q95ofthe Califon
nia Health&SafetyCode,Sccdom2550.23533and25334.1 undcmand drmifW building
dors trot currently have a moot,thea it is my nsponshillly to notify the aaupmt of W
ant nu which am be met prior In issuance of a Cenillcam of Occupancy. Signature Of Applicant Date
14 D 0 n tor.,- 1 . 31- O(a All roof coverings to be Class"B"or better
Owner or authomcd gent Dom - ti