02090041 CITY
BUILDING DIIVIISIONNOPERMIT CONTRACTOR INFORMATION:
BUILDING ADDRESS: PERMIT N0.
10291 PARLETT PL CONTROLLED SYSTEMS OF CALI . 020900}41
ogygg•g Lv,jME: 2283 MORA DR APPLIc 09�06A/2002
I PCH:ONNE[-:llV li SANITARY NO. CONTROLNO.
p (415) 964-8354
W O O ARCHffECr/ENGINEER: p BUILDING PERMIT INFO
H BLDG ELECT PLUMB MECH
ZO zi LICENSED CONTRACTOR'S DECLARATION
9 1 hereby affirm shat I am licensed under revisions of Chapter 9(commencing FU S b e tion
F_ 8 with Section 70(10)of Division 3 of the Basi end Professions Code,and my license �
�§m � is in full force ana effect'y ,A
ipte Licens C ss C�ZO p � Z _
to Da ARCNITECfLeLlerf—
'S DEC TION
h— S 1 understand my plans shall be used as public mcards
5a a
ul p c Licensed Professional _
c s OWNER-BUILDER DECLARATION _
I gamut'affirm on I am.Burin from the Conuns Co ;Any c Lew for the
C?< following ream..(Section 7cmLS,Business and rve.de Professions Code:Any city structure 154
I D which requlrcs n permit reconstruct,alter,improve,demolish,or repair any swment
utel 3$ pn no Is issuance,of requires the applicant for such perms m file o signed statement _
Mnt ho a Ii 'n-sed pun ani lathe erovls{ons of Me Contrrcmu Lucnu Low(Ch pier 9 �A
(c that
ingwirn Sauon71100jof Divsono the
ansemdbi.Anyvi Code) 7. CRI�j\ y�tt 1'bf3 i• Valuation
or Sec he li exempt Mcrcfrom and the bast.for the alleged aempubd Any violation
of Sat Mo t e e undredica6t for apennit subjects Me optician macivil penalty Occupancy Type
,of natmaremanfivena�wreaaagarslsSOB). 301AP—N{# PLUMBIN I"F•' P Y YP
❑I,as awnerofthepropany.armyemplayee:wimwagcsnambaolecampensaran, 303 - ROUGH ME,�CH.ANI��6,,+++A777sssrrrLrrr
will'do"Ike work.,n arl'he structure is not intended or offend for see(Sec:7B .- 304 - ROUGH E tTJJa ctions''"
'Business and Profession,Code:The Convenors License Law does not apply to an -
owner of property Who builds or improves Merron,and who dees such work himself 505 - F I NAL EEE TR I CA
or Mrou h his own employees,provided Nat such improvements am not intended or, -
6 _.....-...
',cooffered, - le.ame ver,the building crap v ntnmldhedidaneyear uildof ""' -50-7-" FINAL- PLUMBING \ - '
completion,fn the owns builder will have the burden of proving Mm he did not build or
improve far parposeof .). 508 - FINAL MECHANICAL
-----
❑I as ow a of j=property..7 m exclusively oImfesng with licensed Cantors m
construct the Project Tapp.70.4,owner o aro property
who
CaMJ mp Connector's themon. ,J 1 C7
License Law does not apply m an owner of property who butlda or t pur M Me
__: _and.who contracts focsuch.prajecu with a contracmrfsl Iicensed.pursuanLre the. _ .. _ __.. _. ._-_ -__._. __-...___.._.._.__._.___..._..._—__.__._. ..._ ...
' CoI me exp License Lew., i
°lam exempt under Sec.' •' -„B"&PCfor Mis ream.
O'wn`er °
Data
WORKERS COMPENSATION DECLARATION
1 hereby a0im under penally of per) ry ne of Me following declarations:
° 1 have and will maintain u Cenifiam of Consent to self insure for Worker's
Compemmion, os;provided for by Section 3700 of the Labor Code, for Me
perfonwnce of the work for which this permit is issued.,
'- °I an.and'will maintain Woiker's Compensation Insurance,.ss required by,Section
r c 3700 of Me Labor Code;for the perfonnmue of Me work for which Nis permit is
Idated.-MYW time,ComPenauon In 11 cecl.am_er�and Pohcy number
't^ tar Gtn ' y.fic,No1♦f5-I,P'aV II_,'• .-.
1 �I ICERTIFICAT NO EXEMPTION EROM WQRKERS'1' \ s✓ —..x �i t,Yn. ...1. n!'�a tl:�.•..r t.
- COMPENSATIONINSURANCEr
-,,.. . .. -._.-.____._— I. _. .._...
his media,need not be completed if the permit is for one hundred dollars
($1 W)or less.)
t candy Marin the rt'ho my mann the t for o h Mn permit a Issued,1 •-
C.,m not employ any person{n any manner so as ro become subject ro'Me Workers'
Compensation Laws of California.Dare -
:-...-. o:
NOTICE TO APPLICANT.the WaT.IL after Comperkingitiswisiocate of Labor Code,you
becomesubjecty with
such provision,
Coion,onion provisionsof the Wbur Code,you must
Q O (onhwiih comply wish arch provisions or this permit shall be deemed revoked.
rp.tbNSem is a cons LENDING AGENCY - "I
t '
o I hereby which that there s construction le drag agency Tasha herfotmahce
Last_'Q of Mework for,whichM penin[ issued(S<c 3097 Ci. ... _ "-------_-
tY - Lenders Name_. -�_ .�:. .i _ _ ... ..... .� .. .. ..._._ ...L _ ._ . . _..__ _.. .. __
Lender's Aadrcss-
V 'I certify.hat I have real this apaicauon end state MaI Ms ider a fi fonnauo.is
(L 9F cmmce I agree to romply,with all city arta county otdinonces and state laws relating
C U to building construction,and hereby outhadie mpresenladves of this city to enter upon
the above-mentioned pmpeny for inspection avpurposee.,,.,
(We)agree to se,maemnlfy and keep hamlless the City of Cupertino against
LLLL V1 liabrl t es judgments•costs and eapcnu h'h may in any way seem..,.last said
C.1' City co sequence of the grant ng nl this
h p rmit.
y\p LICA NT U, QR$TANDS AND WILL.COMPLYWITHAI -POI v(/
- - oGRCE E anorvs,! . ., Issued b, Date
Signhtun ofplannt/Comractor Dale Re-roofs
HAZARDOUS MATERIALS DISCLOSURE
TypeOf Roof,.
.of Will appliam m.future bolding occupant stare or.handle b:zatnaas internal . _ - ...—' —• '.,_
u de0ned by Me Cupertm Municipal Case.Chepra 9.12,and the Health and Safety -
1 .' -�-�.
Cade Sienna Clyai'35JJ(al s ., r' 7 s ' I P r -+3rd ,
°Yei All roofs shall be inspected-prior-to.any roofing.material being installed.
dIn occupantay Am Inrdevices. elan If a roof is installed without first obtaining an inspection;I agree to'remove
Di anct°h ve read the hazardous ma[sed b the Arca Air voileMonag<mepl
Wllthea lie nt or frau bolY y Q Y
emu hazallou a cool na a aadef all new materials for inspection. Applicant understands and will co_mply,with
all non-point source regulations.
enols requirements under Chapter 6.95 of the
California Health A,Safety Code.Sections 25505,3533 and 25536.I understand that
If the building does not currently hese a tenant.Met it is my responsibility to riaufy Me
occupem of the raquiremenu which must be'met prior to Ismence of a Certificate of
Occupanry. ',
Pl`�z- - Signature of Applicant _ Date _
o vora.Mon'.,gent oe¢ All roof coverings to be Class"B” or better"
...... :_. .. .. ..., ._. ... OFFICE — - ... ... .. . .- .... .... ..... . ._. .