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CITY OF CUPERTINO
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BUILDING DIVISIONPER
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BUILDING ADDRESS:
PERMIT N'03120043
'03120043
1005'51 PASADENA AV
OWNER'S NAME:
PERMITISSUEDATE
CHURCH IN CUPERTINO
E:
SANITARY NO. CONTROL NO.
ARCHITEC rENGINEER:
BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
LICENSED CONTRACTOR'S DECLARATION
Job Description
1 thereby affirm that l w Ronald under Provisions of Chapter 9 (commencing
_
whhllfaw,701O)ofDiNaion]of
infallffist
EXPAND ATTIC TO R-3 .(885 S
License Class Liar
Dam COntrseur
I••
ARCHITECTS DECLARATION
_
I understand my plans aull W used u public mcnNs
Nov
- 7V ?00[
Licensed Professional
ION
OWNER -BUILDER DECLARATION
I hereby .(firm Cor License Law far the
11. exempt from me Conine
-
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Code: Any city or
rtnma. (Soden 7101.5, Business and Co
on
Sae, damns icounty
which icquiros a permit ro cottmtuL alms. WProw, demolish, m rtpur any alrmiurt
which
a.
prior in its issuantt, also requai es On applicant for Wch Permit to Ble a signed Nmmtlll
he is licensed the Committees Chase Law (chapter 9
Sq. F[. Floor Area a I amw
that pursuant ro provisions of the
Business Professions Code)
�/(� skY 9T my'
(commencing with Sw on7")of Division] of the and ter
$5'0.0:00-
that W is exempt Ueac(rom and the bub for the alleged nemptioe. My violation of
APN Number
Occupancy Type
Secdon 7071.5 by airy applicant for a permit Subjects the applicant in a civil Faulty of
net man man five hundred dollars (5500).
❑ I, an owner of me property, or my employees with wages AS their sale Compensation,
Required Ins ections -- -
will do thework:and The anlumlanoii.tendedmoffemdforsale(Sec,7044,Bualness
Mmachota
And Professions Cade: The Limine Law don vel apply m an owner of
— — Q P
property who Wilds or improves thereon. and who doesmah wink himmlfar msough his
own employ.. provided Out such improvements an not fnuaded m offered for We If.-
howover, Ne building or improvement is Sold within am year ofcompledon, the owner.
-
builder will have the Wrden of proving abut W did not Wild or improve for purpose of
ark.).
1, u owner of the property, am exclusively cmmucling with licensed Conuacun u
co tinct the project (Sec. 7044, Business and Profession, Code:) The Coetncu'S U.
come law does not apply in an Owner ofpropeny who Wilda or improves thereon. and,
who contracts for such pm*m with a cont law U) licensed pursuam m the Contractors
License law.
.
❑lam asell undersea .Bh PC fm this
Owner Dau D
WORKERS C MP COMPENSATION DECLARATION
I hemby affirm under penalty of perjury ane of the following dechndons:
haw and will maintain •CcrdBnte of Consent to self-insum fm Workers Compere-
- ..
smiun, As provided for by Section 37W of to Vbor Code. for the performance of the
wink for which Nil permit is i.c.
❑ 1 have and will maintain Worker's Compensation Iavwvrec, As acquired by Secden
3700of the Labor Code. far we performance of the work for which this pcimit is island.
'
My Workers Compensation Insurance carrier and Polity, number am:
Cartier: Policy No.:
CERTIFICATE OF MEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(This section road nohecompleted if the Permit is foram hundred dollars ($1014
or lea.)
1 certify Nat In the performance of the work for which this pontic Is island, l shall not
employ any Posen in my manner So as in hccemc Subject in the Worked Compensadw,
Laws of Ca1iwrana. Date
Applicant
NOTICE TO APPLICANT: If. after making this Car incase of Exemption, you should
become subject in the Worker's Compensation provisions or the labor Code, you meal
forthwith Comply with such provisions or this permit shell W dccmed mvokcd.
CONSTIIUC ION LENDING AGENCY
I hereby atlhm that them Is a construction lending agency far the Performance of
the work for which this permit is ivad (sec. 3097, Civ. c.)
Leaders Name
Lander, Address
I certify that I have read this application and sum that the above information is
'
corral. I agree to comply with all city and county ordinances and cute laws mlatlng M
Wilding conduct and hereby authonse repacsenutives of Nis city to tour upon the
above-mentioned property for bUPection purposes
(We) agree in Save. indemnify and keep hmarlem On City of Cuperino against
17we
liabilities• judgments, emu and expenses which may In any way Scene against mid City
in c0nsequencc of the goading of this permit.
APPLICASOURCENT UNDERSTANDS AND WJLJ�COMPLY WITH ALL NON- INT
Issued by: Date
l/tIIT D04Re-roofs
Type of Roof
Sign— uApplicantlContsmmr Dam
HAZARDOUS MATERIALS DISCLOSURE
Will we applicant or forum Wilding occupant shim or handle hazardous material
AS defined by the Cupertino Municipal Code. Chapter 9.12. and the Health and Safety
Code. sacuan 255]2(a)7 /
ONo
All roofs shall be inspected prior to any roofing material being installed.
❑Yes
' If a roof is installed without first obtaining an inspection, I agree to remove
Will the appEcant or future building oeeupaat use equipment or devices which
t havardnu air contaminants in defined by the Bay Ams Air Quality Management
all new materials for inspection. -
let? v
❑Yes M.
1haw mad the hnmdansm Ofthe
/
ria HO.Wrr SafetyCodeA 5515. 5533 itenuunderChapterti.95
Wilding
29YM.lionourndthent Wilding
nshat
> G/7yL
it its nand
Jan not currently how a tenant that It la rtsponsihilidy m nntlfy the oceupant of the
warrant.mup
requirements which mutW tpnorm ern CO.fcate r I"'y.
Signatu of Applicant Date
s
All roof coverings to be Class "B" or better
owns ainonrcaagent ,�