06020031 CITY OF CUPERTINO gra:;tee?Lxxas'Pr?'>t3"k � �"1"'� �aA
BUILDING DIVISION PERMIT °TgO �;gy, OY �� 11
BUILDING ADDRESS: + FERMITNO.06030031
20900 MC CLE[
OWNER'S NAME: PERMIT ISSUE DATE
NEW LIFE CHURCH OF NAZAREN
E: SANITARY NO. CONTROL NO.
ARCHITECT72NGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
�oo LICENSED CONTRACTOR'S DECLARATION Job Description
i(ys 1 baeby affairs Mo,1 am thenad under provisions a Chapter 9(commencing P
with Section 7=)of Division Jafthe Budass aMPro(y�n�p�e aMmylicusxu
+� ifull force and effim LL4 YQ`� , T. I . -LIGHTING/DWITCHES/OUTLETS/HANDICAP UPGRADE
Lh""` Lm'"� NEW WALL AT AUDITORIUM/2 (N) EXIT DOORS
S ip Dam ARCHITECTS DECLARATION
E 7W 1 understand my plea alWl he used as public accords
>yU
ted Livened Professional
1or� OW NE R-BUILDER DECLARATION
2 a I hereby a(Rrm that 1 1. tamps from the Coitions o :Any c Law far nc
p o following reuaa.permit
t 7(D I.3,Business and ere, evua Cade:Any city or county
e$�s which requires a e.Win re ennswct almc.improve,for m,demolish,or repair soy thuttum
°i�^ PAormiu Issuance.ale requlma the applicant for ech Farrah ro filc,signed statement
¢gip then he is ueaad pufwant to do,pm.aioa Of t e Contmamre ueae Law tchamer 9 Sq.Ft. Floor Area Valu iU10 0 0 0
5 9 (cmnmead.&wish S.-tion 7000)of Division 3 of the Borrow and Profession Code)or
s dot he h ea enin therefrom and the bath for the,login esunpdm MY violation of
Smdon 7031.5 by any app0ont fm a permit subjects;the applicant m a civil pauBy of QpTpy��♦�N,y}7�N�,`7umber Occupancy Type
not mart than nem hundred dolWs WWI, 35920029 . 00
❑I,an owner of Me property,our my employees with waga a their role eempematia.
will do tht woA,and s:1z Commerce,Lt.. A.does Out apply w an B mer of Re uInspections
and 0 die work Cade:Tho CenOMbA Llaav lave sive Out apply ro,n owner Of 9
property who builds our Impairment thereon,and who dao such work himself our through hu
awn employee,,provided thatsuch bnprmemenu are rot inurtlnd aroaerzd fossda.if.
however,the building our Improvement is gold within ons year of empledan.Me awner-
builder will have,the bund-s of proving that be did wt hours or improve for pompons of 1�/J
au.I.
❑I,as owner of the property,am sin aeively conuanonal with Seemed mn�m i- /
eomwet cite project(See.7004.Baines and Professional Code:)Thaves ft ..LI• ^
• sae Law date not apply m in owner of property who builds or Improve thereon,W. ll
who comment for such projects witsaeanlncmr(U licensed pammm,in the Co dommes
License law.
❑lameaemptundersen .Ba PCfcrLhil too
Owner Dau
WORKERS COMPENSATION DECLARATION
I hereby alarm under porosity of perjury ons of de fallowing declaruiaa:
haw and will mainWn aCerlfrau of C.me.I to alf-inure forlarOft'sCampe-
salon,as provided fur by Section 3700 of the labor Cade.for tee perfam Bane of tee
work for which this permlt is inner.
❑I haw and will maintain Workels Compemalon Insurance.as required by Sectio .
3Mof the labor Code,fa tee perfamtana of the work forwhich this permit is isauN.
My Workers Cnmpeassi Insurmse senior and Policy number are:
Cartier. Policy No.:
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE a
(This seNa need et hccompkud It ft permit is farad hundred dawn(giro)
or int)
1 certify Not in the perfmmame of tht work for which this permit Is issued,I shall out
employ any person in any mannere as in become subject to the Warkw'C"mpemati"n
Laws of California.Dam
Applicant
NOTICE TO APPLICANT.If,afe,making this Car inane of Eaemptian.You should
become snbjat an tee Worker's Compensation provisions a the labs Code,you mute
0 O LEN
forthwith comply with such provisions or this permit shall be domed revoked.
„z,r^ CONSTRUCTION DING AGENCY
[-t 1 hemby alnmm then then I..commelnn leading agency for the Performance of
ori 7 the work for which this permit is Wad(See.3097,Civ.C.)
�W QLender's Name
Z LcndeezAdd.
U O I amfy that I have read this application w mate thin tho show information is
U.f~- coma 1 agree m comply with all city and county aNinafrces and sum hems rehdng u
OU buildingconstruction,and hereby audionre repreanmiwt of this city to enter upon the
t27 aluw-mentioned property for inspection purposes
f.L (We)agree to save.Indemnify and kap harmless the City of Cupertino against
tits
liabilities,judgments,cow and eaperms which may In any way mama against said City
U In consequence of the grunting of this permit. Q
AP LICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT Issued by: Date
S RCE R Uy�pgy� �� � .�
ryy, 5V_, �`� S/��Oi/ Re-roofs
ore of Applamcanuanaf Dau
HAZARDOUS MATERIALS DISCLOSURE Type of Roof
Will ft applicant of to=building a0.lpel N"re Or handle haaNOa samurai
as denad by the Curricular,Munici at Code,Chapter 9.12.and the I mics and Safety
Code.Sadao 235324)7 All roofs shall be inspected prior to any roofing material being installed.
❑Ya Na
Will the applicant our future building aeulim,um equipmet or devices which If a roof is installed without first obtaining an inspection,I agree to remove
t hvaNna air contaminants as kneed by the Bay Area AIr Quality Mangement all new materials for inspection.
ltrtcl7
❑Ya Na
I have road the h motions Modehrequiromenta undcrCha nor 6.95 of the Califor.
nia Health A Safety Code,Section 25505.25533 mo125534.1 undersand thin If the building
does oat cu.dy It w a tenet,Wt It h my respamlhi0ty m notify the aeeupent of the
re menu afaCttlflatearoc Signature of Applicant Date
arixd agent Data All roof coverings to be Class"B"or better
Owner a wth '