08080191 CITY OF CUPERTINO -d'
BUILDING DIVISION PERMIT sCON=TR N
4.CTOR`T '�.'bC}� TIgN `
PERMIT NO,
BUILg1MlbRFsHS:OMESTEAD RD TBD - TO BE DETERMINED 08080191
6"ER'S NAME: PERMIT 15917E DATE
09/05/2008
PFIDNE: SANITARY NO. CONTROL NO.
ARCxrfECTfENGIMER: T. I COMMERICAL BUILDING NAIL 'BLDG BEING PERMIT INTO
MEcx
0 0 0 0
.sao LICENSED CONTRACTOR'S DECLARATION lob Description
ed
Z 1 toreby m".Nat 1 am licensed under pmviilons of Chapter 9(commencing p
n< vAuSeeum7plU)af Divhknlof the Butlness and Prafessiom de dmyfjceneh
<=e m full force aM effect.2 Li" Clm Lie 0
Canuao
ssum
ARCHITECTS DECLARA N 1
p < I uMersund my plans Nall he used ss public rtmrds cc Ac[Tckd ivL
lyU
k G Licensed Professional
3 OWNER-BUILDER DECLARATION _
1 hereby aRrm Nn I am exempt from the Contractors License Law for the
is
Oct (ollowing wan.(Section 701.5.Board.and Pmfessiom Code:Any city or cemay
$8! which requites a porton in crwmn.alter.Mpmve,demurisk ar mpoir any surmounts
prior to its issuance.Abu,requires the applicant for such permit m file a signed statement
< that he is licensed pursuant m the provisions of the Convector',Lane Law(chapter 9 Sq.Ft. Floor Area Valuation
y�$ (commencing with Section 700)of Division 3 of the Business and Prefessiom Cock)or
— Nu he is exempt themr.xsl m basis for the•Ikgea uemption.My violation of
Section 7031.5 by airy applicant for pesmfsubjttu the.pplkrvtto a civil penury of APN Number Occupancy e
ms mare Nu five hands da1Ws(S50I. P Y EYP
Luaw ref Nefts=,a4 bony dwithemdfu Ne'v.rokcom.Bumen,
wid dotiro want Code:
swcNrt aroakemkd or t.4 fmaakpply in An...
ane property
coda:The ConvacmYs head
wtse Law aelt oaks apply if rt owner of Required Inspections
pmpeny who Wilasaed Mat uch improvements
and who AM not tr wolf himulfm Nor We his
awnempkyces,Provided Nerouchimpm old wit in rotincndWnaplemed me sales,
however.Ne building m improvement h Gold within arc year of completion.Nepose of
Ask.) will have Ne burdu of proving Nat W did nm build or Improve Tar purpose of
uk.).
0 1,As owxr of Ne Pmpenr•am delusively contracting with licensed contractor N
construct she project(See.7044,Business aM ProGasau Cade:)T7c CwUwtoe,U.
ceva Law does out apply or an owner of Property,who Wilds or improv thereon,and.
who conducts for such gnjects wish a conductor(s)licensed pumunt m the Canvacsofs
Licme law.
❑IamexemprunderSee ,B&PCfmdai..n
Date
WORKER'$COMPENSATION DECLARATION
J hereby a01m under penalty of Perjory arc of 0x following declamations,
O ham and will munain a Certificate of Concerns m elf-insumfor Wasters Compen-
Minn.As provided for by Section 370 of Ne Liber Code.for Ne performance of the
were:for which this;permit is issued
❑1 have.rod will maintain Work ea Compensation Inco ..As required by Section
37()Oof Ne Labor Code.for Ne peruses.of Ne work for which this permit is issued '
My Worke(s Comaematim Insts.carrier and Policy number art:
Carrk,: Policy Nc.:
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE ,
n1thsmAon red rot W cgnple.d Irthe permit Is(cram hunthNdoRan 1510)
or less)
I cartify Nat in the performance of the wart far which this Permit is used 1 shall not '
employanypteeminanyacture o lobecomo bjecrmthe Wmleti mN
Compem
laws of California.Dae r'}G7�
Applicant mf�r_c-
NOTICE .Ir aftErYfialsing this Certificate or Eathopution,you.should
become subject re the Worker's Compensation Provisions of the labor Code,you most
.JO Forthwith m Ndeemed m
hwith comply with such pervisu is permit mol W essed,
,z.i Fr CONSTRUCTION LENDING AGENCY
r
f" hereby which
out there Wood(Sucumknaing agency for the peeformare of
ai Le soh for which Nh permit h issma(Sec.3(197,Civ,C.)
Q Lon ees Name .
� z Lendefs Address
U O 1 certify that I hate rust this application and sum that the shove information It
LT.H ounces.I agree to comply with all city and county ordinancea and fou laws relating to
U building construction,aM heeby admode representatives or Nu city to ends open do
ranoper
aWiliti ju gm nts.co Yfar inspection purpowhich ms
F 4 (We)agree to ase.indemnify and keep hamku the City of Cupertim again,
W liabilitiu.juagmenu.emuand expen..s which may in my way acrncagainst said City
U z
APPLICANT UNDERSTANDS NUIDD WILL COMPLY WITH ALL NON-POINT Issued by: Date G�
SOURCE Rf1 U TIN Oq/CIC/Oy
Re-roofs
nsrtofA IinR
HAZARDOUS MATERIALS DISCLOSUREC/
Type of Roof
Will the applicant or future building oaupmt some or handle hazardous amwnal
As
t=�'
0md by me Cupertino Munic' al Cade.Chaple,9.12,and tie HnIN and S.rety
.Section 25532(.)?
❑Ya Na All roofs shall be inspected prior to any roofing material being installed.
Will me. liant car rutae Wilding acv If a roof is installed without first obtainingan inspection,I agree to remove
PP g pant tic equipment or devices which P
hvardnu our canuminanu u,defincd by lite Bay Arta Air Quality Mmgemcm all new materials for inspection.
c1T
❑Yu u
I have mutt the hvsedous mamriab rtgchour ems under Uupkr6.95 of the Cali(or-
eaINRS.retyCode.Sumiom25505.25533 am125534.1 undrnuna Nm ifdc Wilding
nol cuncmlY Ana
4mank that it h my rtsponsmuhy m merry Ne mse"Wt of Ne
rtquimmcnu whk m L, 'oetyfssumtec car.Certifcae of
Signature of Applicant _ Date
—S- —.�'I/` 'T-�/� All roof coverings to be Class'%W'or better
Owner or authmiv .gent Dom•