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CITY OF CUPERTINOr
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1 BUILDING DIVISION PERMIT
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BUILDINGADDRESS:
SILVER STAR DEVELOPMENT
PERMITNIb5060223
ER'S NAME:,
PERMIT ISSUE DATE
CHURCH IN CUPERTINO
16294 R DG
2005
PHONE:
SANITARY NO. CONTROL NO.
408)399-7447
ARCHITECTIENGINEER:
BUILDING PERMIT INFO
BLDG ELECTO PLUMB MECH
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LICENSED CONTRACTOR'S DECLARATION
Job Description
I thereby reby aNet I am licensed under p ..We. of Chap¢r 9 (cemmencing
o
with Section 7010) of Division 3 of the Btsmeas and Praicssio-cal •dory license is
in full farce and effec4
7r�'3 S"`'L
REVISION --ADD 2 WALLS
Llcem Chun -4- .♦
NO NEW PERMIT ISSUED/ORIG. #03120043/#03120042
Dem Canxor
ARCHITECT'S DECLARATION
1 understand my plane shell m used As public records
Lleeued Profmional
OWNER -BUILDER DECLARATION
I W roby affirm Nm I em exempt from Ne Contractor, License Law for the
following reason. (Baden 7031.5, Business and Professions Code: My city or county
which requires a Permit to construct, alter, imprew, demolish. or mpah my mature
prior to its Issuance, also requires he applicant forsuch permit In IIIc a signed atamment
dem he islicensed rumse Othe an
mer Om .vision of Camebu's Lm Law (Chapter 9
Sq. Ft. Floor Area
Valuation $0
(commencing with Session 7000) of Division 3 of Ne Business and Protections Code) or
that he is exempt Nemfrom and the bub for the alleged exemption. My violation of
Section 7031.5 by any' applicant for a permit subjects the applicant On a civil penalty of
APN Number
Occupancy
p y Type
not mart Nan ftw hundred de1Ws (55110),
35717041.00
0 Lae owner of the property, u my employees with wage u Near sole ampen dation.
Required Inspections
windothe.rk.andthe Honorelsnot Intendedmasteredfua (See.7044,BusiMss
and Prole dais Cade: Tho O mnemes Liam Law dace an apply to an Owner of
property who builds or improves Nemon, end who does such work himself car through his
Own employes, provided that such Improvements Are not Intended aroffened foraale. If.
howem, Ne building or impmwmmt Ismld within Om Ras ofmmpieuon, the owns-
A
builder will have the burden of paving that he did not Wild or improve far purpose of
sale.).
0 1. u owner at Ne property, are exclusively eantmaing with licensed cpnUKbrs to
construct the project (SeeJ0a4, and ns Code:) The Contractors
d
owner of or Improves Kneen, and
of paper( who
ecus law dons not apply ny who
s
\
sdbuilds
who contracts for such projects with econusemr(s) licensed punusm in she Contrxmfs
a is witha
License law.
_I�
❑Tem exempt under See. ,BkPCfar this reason
\�
T Dam
WORKER'S COMPENSATION DECLARATION
I hereby affirm under penalty, of perjury one of the following dalsnuou:
I have and will maintain a CeNOcam of Consent to selhlnmm far Waders Compcn-
a.. u provided for by Section 3700 of the Labor CoM, far the performance of the
work for which Nb b mused.
ed.
❑ I have and will maintain Worker's Compcmadon Insurance, As required by Section
5700 of be labor Code. far the performance of the wart for which this permit is issued.
My WarkeB ore emuan Irma 'm and Polity number am:
Caller. 'T Policy No.:
C'R • GATE OF PrION FROM WORKERS'
COMPENSATION INSURANCE
(11hissectlnn need mawcmnplemd lithe Permit b fmanclasmin d dollars ($100)
an, leu)
I certify that in the performance or the work for which this permit is issued, I Nell not
employ any person In any mannast u in become Object to tm Workmi Compeudon
Laws of Califomie, Data
Applicant
N0710E TO APPLICANT: If, after making this Cenlacam or Exemption, you should
became subject In the Worker's Compcmtic n pavbions of the labor Cade, you most
forthwith comply with such provisions or this remelt shall he dcaornd rewhaL
,
CONSTRUCTION LENDING AGENCY
I hereby &Dian that Nen ba construction lending agency for the performance of
the work for which this permit Is issued (Sec. 3097, Civ. C.)
Lenders Name
-
Lender's Address
I comfy that I haw read Nb application and Nm that um aWw information At
torten. I agree in comply with all city and county omdimes and stem lam relating in
W (Wing construction, and Mmby sutharice mPmsen sfim of this city m enter upon the
above-madoned property for Inspection purposes.
(Wa) agree in taw, Indemnity and keep harmless the City or Cupertino against
ITabili0es, judgments. costs and experts which may in anyway sarm again said City
Ia consequence of the perming of this permit.
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON -POINT
Issued by: Date
SOURCE REGULATIONS.
Re -roofs
Signature of Applican✓Conmactor Dam
HAZARDOUS MATERIALS DISCLOSURE
Type of Roof
Will Use applicant or future building occupants me orhandle hanrdons msmrisl
-' Med by the Cupertino M iclpal Code, Chapter 9.13, and the Health and Safety
section zss33(e)7
All roofs shall be inspected to any roofing material being installed.
❑ Yu o
prior
If a roof is installed without first obtaining an inspection, I agree to remove
Will the applicant or uturo Wilding occupant use equipment or devices which
emit huardaussircomman A u dcflwd by the Bay Area Air Quality Mmagement
all new materials for inspection.
District?
[3 Yes Nu
I ham read the ousmamrielsmquiremens under Cltspmr G95ofthe Califon
Hie He stth are,o 355U�35533 and35534,1unanswulthatirbe Wilding
does Out moan et my rerymuih' ty notify theoccupant of im
require _ 1 comm p umccOra am 0fOccapw"i
Signature of Applicant Date
l
All roof coverings to be Class "B" or better
Own
amharip<O a t Ds m
e