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CUPERTMOBUILDING
DIV1310N PERMIT
F�CITYOF
DING ADDRESS:
CHURCH IN CUPERTINO
PERMIT N`04120047 "
V
6051.PASADENA
ER'S NAME:
PERMITISSUE DATE
— CHURCH IN CUPERTINO
4
PHONE:
SANITARY NO. CONTROL NO.
ARCHITEC (ENGINEER: -
BUILDING PERMIT INFO
BLDG PLO
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LICENSED CONTRACTOR'S DECLARATION'
Job Description
1 hereby affirm Nal 1 am licensed miler previsions of chapter 9 (commencing
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with Section 7") ofDlvislon 3 of the Business and Profesdom Code. and my license is
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Infull mrceandeRac4 - .:
REVISION --IN HOUSE USE ONLY -'
U¢nm Clan l&, lr
Dam coorsew,
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NO NEW PERMIT -ISSUED- ORIG. #03120042
ARCHITECTS DECLARATION
1 understand my plans &hall W used u public records
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Licensed professional
.. OW NER-BUILDER DECLARAnON
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1 hereby Bffirm that 1 am emmpl from Ne Common's License taw for the
following mason. (Section 7031.3, Business and Profession Cale: My city or Monty
which requires a peail In comment, e@; improv, demalbh. or repair my structure
prim to its isswnen, also requires site applicant for such permit to rile a signed statement
that he is licensed Punnent to the previsions Of the Commutes leen❑w(Chapter 9
Sq. Ft. Floor Area
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Valuation $ O
(commencing wit Section 7000) or Division 3 of the Business ad Profesdou Cade) or
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that he Is exempt thetefrun and the bub for the alleged exemption. My violation of
APN Number
Occupancy Type _
Sudan 7031.3 by airy appikam fora pemrlt subjects the applicant to a civil Penalty of
not mom than It. hundred dollen ($300).
35717041 .00
1, an caner of the property, or my employ= with wages u their note eampeswim,
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- Required Inspections - -;-.- • `7"r'"..:.zl'�
eer
mil dodtesome. and Nemuctun is rwtintended oralfemd far sale(Sec. 70th, Business
and Premum. Code: The Continuities=a= rem of
Continuities Lice law t apply an own
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property who Wild, nrlmprowa daamn, and whad=tucllworkhMselforNrough his
own employ=, provided thaLLtmh ImpoevemMts are notinsended oroRered formic. If.
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however, the building or improvement is within one you ofmmpledon, the owner-
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builder will haus the basun of proving that he did Out build or improve for purpose of
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4.t 1. as owner of the pmpeny, am emlutively comraolog with licensed conommn W
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cc= Ute Beacons and rto(Goom Code:) The Coneacmr', U.
not (Sea
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La es tom umer and
pr man ofproperty messed aorimprowa Nemen.uarl,
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who contractssuch ithA
Lk"m nem for each projects wlNacanuacmr(a)IlGued punwntm the Conuaaott-
Lkense Law.
Inures under Sac &PCfor Nis Mas
er e 6WOR
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COMPENSATI NON1hereby
Not
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affirm under Penalty of perjury one odens:
❑ l haus and will maintain a Certificate of Conaem to selGhaue for Wurkefa Carolina.--
satlan, u provided for by Section 37M of the labor Code, for sire performance of the
word for which this permit is issued.
❑ 1 have and will maintain Worker's Compensation Insurance, at required by Sedan
3700 of Ute labor Code, for the performance often work for which this permit is Issued.
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My Worker's Compensation Immance carrier and Policy number tae:
Carrier: Policy No.:
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CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(Thls rahM and Out be completed if the permit isforone hundrad dollars (SIM)
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or tea)
I edify that in the performance of Om work for which this permit Is used, l shall not
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employ any person in my counteract as in become subject mile Worker'Compensation
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Lawa of Csiifamie. Dem
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Apt mant
NOTICE TO APPLICANT: IL dwr making this CenlRcate of Exemption. you should
become subject in Ne Worker's Compensation provisions of the labor Cade, you must
forthwith comply with such previsions or this pewit thall be accrued memted.
CONSTRUCTION LENDING AGENCY
I hereby afires that Nene is a construction lendingageney for the perionom not
the .,it for which this pewit is issued (Sec. 3097, Civ. C.)
Lendefs Name
leaders Ad0muz
I =try that I have =d this spit ki aon end m c that the above information Is
comma I agree in comply with ill city aM county ordinances and sum levo missing to
building construction, and hereby mNarie, representatives of tis city a cater upon the
show -mentioned property for inspection purposes.
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(Wc) egret to saw, indemnify ad Ieep hilnleu the City of Cupertino against
liabilities, judgments, nouns an GG which may in my my eceme against said City
in conmgonnce of c ts
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grand 1.of permit.
PPLICA ERST D AND WILL ALL NO - INT
Issued by: Date
b L TION .
Re -roofs
Type of Roof
signature tAp,maiwContradorase
HAZARDOUS MATERIA DISCLOSURE
Will No applicant or fuuue building occupant nom orhandle huamous material
fined by the CupeNnor Municipal Code. Chapter 9.1x, and the Health and Safety
xss3zfa)7 fns
4. Sc y. i
❑Yes
All roofs shall be inspected prior to any roofing material being installed.
If a roof is installed without first obtaining an inspection, I agree to remove
Will the applicant or future building =upset use equipment or Jcvlm which
emit hazardous air contaminants u defined by Out Bay Arca Air Quality Management
all new materials for inspection.
Dimict7
❑Yes u
I haw mad the hwnfoyy some a myuimmenu under Chapter 6.93 oftitcralfifor.
nb HMlth&Safe/tiCode,S Ao 25305, 25533 am 25334.IundentaM thulfth ilding
Jars m omen S haw a an4 hu it b my res mihilhy m netify tie accu t of the
myui inmwbeme dors i nae ar Af mora r I
Signature of Applicant Date
"B"
All roof coverings to be Class or better
owners oath , aas DBm