01100019 OF
CI BUILDING DIIVISSIIONNOPERMIT CONTRACTOR INFORMATION:
BUILDING ADDRESS: PERMIT NO.
20706 KIRWIN LA CUPERTINO CONSTRUCTION INC 01100019
OWNER'S NAME: APPLICATION SUB DATE
DANNY LEE 10079 SAICH WAY 10/03/2001
/ PHONE: SANITARY NO. CONTROL NO.
l (408) 253-9000
w V ARCHITEC[ENGINEER: BU ING PERMIT INFO
BLDG ELJkT PLUMB MECH
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LICENSED CONTRACTOR'S DECLARATION lob Descrlp On
I hereby affirm(hat l am licensed under provisions of Chapter onerneecing TEMP POWER POLE
Section 7")ofDivision 3oflhe BP,iPes,.Pd Pmfessiam Cale,and my license
m fall foam and ell-eet. �2 •� F9 Q
:xZr V
«ct< sense Go, /J Lic.N
O 6 O tale Contraflar
1 - — ARCHITECT'S DECLARATION
I understand my plancypall be read as public sai
ae
1 o O Licensed Prefa,,mrul e � C''/
OWNCR,BUILDER m the C.AT10N
1 herchy,(firm on I um exempt from the Conlon,',License Low o lar mm
F' following reason(Section]1131.9.Business andmpr ve.de io demolish.
Calc:Any city steoumy $200
Y 5 O which acquires a pcmtil to contemn.alma impmvc,h cervi sh,or midi,any amours
i3m �Wi«tos liavAdpmuruibt a thents lbevvsmnc o for Cmddacmil w Ne v,Law(ompaerll t - - - - --- - - ---- - ----V -`-- ---- _
Ihdltieislicanad PSectio no00 of Drsisiof me feBusines License Lawort,Cmr9 CO". F ,x� -with Secuon]WO)rfhe bsisoofine BuetwaxandimfAnyvi Cade) - t3 A{Ba., area ion
or that io is exempt thcyidm and the bears for Ibi alleged excmpdoh.Any violation
-of not Section 7031.5 n iv any hundred
doll far a permit subjtte me epplicaano d civil pcwlty'
' tate«fame man Eve nanarcd aouat.Issoo). 10 J1PN Isfy'K : Occupancy Type
❑i,as owner of the property,or my employees with wages as their sole compensation, -4 net ]Rr)JJaJ1 PT7.rT]RTrAT.
will"Jo the work,and the murcloc is not Intended or uIT..d far sale(Sec.7044,
Bu3imss and Professions Code:The Convector's Licata Law fres not apply to an Required Inspections"r '
x'nc
r of Pmrery who builds or imPmvm thercan.a.d who do¢such work nim Jf
m Io video Thal such ire .is voll a i nm I arm
.of
or Through his own e p yccx.pm r
yoRncd far sal,.If,however,the building or urden ofmrm,is sold vermin one year of --
c Nola lin,lhm owns-buTdm ill h me bore f Previn6 that he did not Wild or
pm r P moss oriole.)
---
Q 1. be,of h
reopen, IYMn d mora
construct m m3 u(See 70,14.B . d Prefextion. Code:)The Cotremors /-O , �V(
ell eW J apply loan fWilds YI'
1.t
Pn rery h hu ian " p thereon
0nd wh t t. for such.projects. ith u farts)(Lensed-p rs m uo the ..
C m t L Ir
Blame mptunder5e r .6&PCf Ibisremon i-'�) i.s�' Iwo.
Owner'.- one.
. , _ J
WORKER'S COMPENSATION DECLARATION
! - I hereby offimt under penalty of perjurytone 1.of the following declarations:
g ❑ I have'znd will mwmaid'a Cmificaic of can..emld c),own, fm Wurka•s
{ Compensation, ax IorMdad for by Section 37Wofthe Lab« Cada. far the
_ performance P ire work for whim this permit is issuW.., _
❑1 have ad will maintain Wo,kar x Ccaipeexatiou Insurance,as quire)by Sees..
3] of the'labor Code,for the pcRonhetac of the work for which mix permi(is
C recd MY Workers Compcnwt onl . rant c e oMPo&Y numM are: "
Earner PC6 A1Ca. PolicYNo F114W 999�3d'dl� x..- e' r-'-•r rt,a, +r�r'�or -- ._. _...
' 'CER FICATXEMPfIONFROM,N' RKFr S,•' {I- 1 •a �.' �B I.. -.t• `_t-1, r4! y(, ,•
r NINSURANCii
• rN N _.._.__
MIh ITh,seengn need not be'em IcieJT the .it is for one hundred dnllan 3.1.� • ''1 t!',:C;f pawlj pi
IcarYfyhat in th pert r _ fllrc work fw whits lh pe 1 ssu i;I 0U:i.0 Ii' V,ros,".: '
shall non employaa,persm m any manner w as io became bla,uo fie Workers "-
cimimira'.Laws ofCalifornia.Dae' -
Applicata. .. .. ... -
,.NOTICE TO APPLICANT:If.ofer making this Certificate of Exemption.you dodd
Z become subject o the Worker'a Compensation previsions of the Labor Cale;you must
Q 0 fonnwith comply with such provisions or this permit shall be deemed revokmd.
'rA 'u ib CONSTRUCTION LCNDINGAcENCY 1 -
f✓ I he nY flirminm itis 2- o.w 1 Ind g Deco Y f th perfnmanic I 't : . - 'lit -
r
'olthe work forwhich thP,rut ,issued(S- 309] Cir.CJ
l:ender'xName.0 .,..._r em.. ..
.';z
.V O 1 candy that I have nae this application real sale mm the above information is
correct.I agree to comply with all city and county,ordinances and state laws relating
O.V to huildlog convection and herchy0mhorim mpreummivea ofthix city to enter upon
the above mentioned prnpeny for iropecLum putpasea., _ .sitarist F-y (Wdagrmems.ve.irdemnifyand keep hdrmlesitheCityofCupininoagaimt
W liahiliums,judemems,c 1,oad expenses which may in any way,accrue g.,P,,said t
City in'conscyvence of In,g.air,of this permit.'
sOUMCANT RCEREGULDAT110N5NDSAND WILLCOh/PLY WITH'ALL UON-POIN'�' Issued by: Date
- Signamret al'Appecanvicentmctoq '.I i.Dam: Re-roofs
HAZARDOUS MATERIALS DISCLOSURE
W 11 the appliam er(wrc bode g oavpal l «haM1e hvaN �r�alerm Type of Roof.
as defined by.the Cul,aninoMunicipal Code Chapter 9.12.andfl Health and Safelyr 1 3 t .•, I
I,
Cad Section 25532(01 ::r - .,y r V '1 s '- s 1 'l �)
❑Y IiN I r ,
All,roofs.shall be inspected.prior_to.any roofing.material_being-installed.-__ ......_.
veli he Prre, n I 1 s "Id"ng ,.pant uaega p 1 ere m,. m,n If a roof is installed without first obtaining an inspection;Fagree`t6"re-move
error ..idea,or cont t.ri defined by the Bay Am Air Q IIyManagement
oat c. . all new materials for inspection. Applicant understands and will comply,with
T. °Ye' ON. -all non-point source regulations;
ll I ha d the ha red nate nal, qe etrcnti'wde Chapn 695'of the
u
California Health&Safety Code.Sections 25505.25533 ral 2553x.l.undersend that -
if tm(wilding d«snot curamly have.endm,par it is my responsibility la ratify the
" sup nl f the iequiaments which sl be m t p t vuan f a Cenificam of
11 °" w`y1 't _ � 3�'� Signature of Applicant . - - Date _
'owns,or aamonae�.igcnn' Dole All roof coverings to be Class "B"or better
OFFICE
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