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CITY OF CUPERTINO7ae.+xr
°'�ACONTRA.CTQRANFORMATI ;
BUILDING DIVISION PERMIT
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Bu1LDING ADDRESS:
O
AC
APVE
SILVER STAR DEVELOPMENT
PERNO.05070193
OWNER'S NAME:
PERMIT `ESUS DATE
CHURCH IN
NE:
SANITARY NO. CONTROL NO.
408)399-7447
siITECTAINGINEER:
BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
0 0
LICENSED CONTRACTOR'S DECLARA710N
lob Description
I hereby affirm that 1 Am licensed under provisions of Chapter 9 (...Arcing
with Sccuon7")afDivi of Ota Busintu and Profcaaino Cole. antl ylicamc is
i t full fore. antl arcccL `7073 SAF
REVISIONS -REPLACE 2 UNITS COMMERCIAL
License Cl Lc., / dd'-..JJ
rota Comm
.HVAC
RELOCATE ONE�REDUCT PER NEW PLAN
CHTECrS DECLARATION
IN HOUSE ONLY -NO NEW PERMIT ORIG 03120042
I roma myP mshallbeusedAspublicrecords
Licensed Prokusional
OWNER -BUILDER DECLARATION
I hemhy Affirm that I am exempt from the Contractors License Law for the
fallowing mason. (Section 7031.5, Business and Profemiona Cade: Any city or county
which requires a permit In contract, alter. Improve, demolish, or repair any structure
prior it) Its ismancc. also requires the applicant for each Permit to rile a signed statement
Contractor's license lJW(Chapwr 9
Sq. Ft. Floor Area
Valuation
that M is licensed pursuant to the provisions of the
(eammancing with Section 70 B) of Division 3 of dC Business And Profession{ Cade) of
$ 0
hub far the alleged mu mpuan. Any mutfort of
Out he b exempt therefrom and te h
y
APN Number
Occupancy Type
Section 7031.5 by any applicant for o Permit subjcm the applicant to a civil penalty of
not mom Nan five hundred dollar ($100).
❑ awrwsof the popmy.oc withwe{esas uWon,
Required Inspections
,.1imaedes
ME do antl the n mss focss (Sm. 7044,
a4,..
aw
O Conam.
PrOsewock,
of
do gr
Cade: The Cmntrmen. Mame use does rot appy lf an
and Licenume Apply he
q P
and who dnaashwork ro is
property who Ma
propertywhobuilds iimposech
oroffeedthrough
own employees, provided that such improvementa arc rot intended oro0do foe
improvements
own e.
however. the or Is sold within of war ar cemPv , the own¢-
d. of pmenn
for
builder Nn have dse burden of purring Out he did not build m improve far propose of
avc the
\
sale.).
❑ 1, an owner of the Property, ata exclusively convecting with licensed cunuadma to
, r
V
conswct the project (Sec. 7004, Business and profession Code) The Commerce, Li.
came law does not apply in an owner of properly who builds or improves Income. and
v
who cants, for such projects with acammetanis) licensed moment an the Contramme,
License law.
v
❑ l oro exempt under Sm. .B B PC Loc this wan
j
Fvnar Dam
'T
WORKERS COMPP.YISATION DECLARATION
I hereby affirm rc under penalty of perjury aof the following dalaradom:
/�
inm for Workeea Compere,
haw and will maintain A CCnNcam of Consent to sel6au
m provided for by Section 3700 of the Labor Code, for the performance of the
for which this permit is issocd.
❑ 1 haw and will maintain Workers Compensation hourana. As required by Saxon
3700 of Inc Labor Cade. for Inc performance of the work for which this permit to issued.
My Works C )peuatlan In Rata cartiej and Policy nu am'
�yr �C� D`
����/Poliry No.:
Caller.
CE IFlGfE OF FJ(EA3P770N FROM ORKERS'
COMPENSATION INSU
(This occum need oat he rnmplemJ if the pe rt, awronchundre do ua({100)
or los.)
I certify that in the Performance of do work for which this pertit is issued. I Nall not
employ any person in any manner. As In Wean a subject to Ineworous Compmedm
Laws of California. Dao
Applicant
NOTICE TO APPLICANT: If, after making this Certificate of Exemption, you should
become subject in we Wmeu r', Compensation providons of Int Labor Code, you must
foMwith comply with such proviAiam At this permit shall be deemed revoked.
CONSTRUCTION LENDING AGENCY
1 hereby afros that them is a construction lending agency for the performance of
the work for which this permit N issued (See. 3097, Civ. C.)
'
Lenders Name
Lender's Add.
1 certify that 1 haw mad this,pplicatien and sate that the allow information b
'
correct. I agree to comply with all city and county ordinances and into Iowa reining in
building con.oclion, and hereby authodm representatives of this city to enter upon the
&Inoue -mentioned pmpeny for inspection purposes.
(We) &gone be save. indemnify and trap harmless the City of Cuper im All
j liabilities ,judgments. con, And expenses which may in any way.cow against said City
in s pcearth.
NTUNDEof the RSTANDS AWILL COMPLY WITH ALL NON -POINT
APPLICAAANranting of )ND
Issued by: DateF �O-a7 f-
SOURCE REGULATIONS.
Re -roofs
Type of Roof
Signature afAppli_ _ar HAZARDOUS MATERIALS DISCLOSURE Dau
Will the applicant or forum building occupant stare or handle hazardous matenat
As dented by the Cupertino M deal Code. Chapter 9.12. and the Health and Safety
Code. Section 75532(a)7
All roofs shall be inspected prior to any roofing material being installed.
_ �❑Yue No
If a roof is installed without first obtaining an inspection, I agree to remove
Will the applicant or fu building occupant use equipment or devices which
JI hazardous air contaminants As defined by the Bay Aon Air Quality Management
all new materials for inspection.
bt7
❑Yue Nu
T haw mW the ham 3 mterials requirements under Chapter 6.93 of the Colifoo-
.is Heal SafMY oro 233113135373 An 4.1 deretand Inaifthe building
Jac, c len 6 w4 Is my rospomi it nobly the =upset of the
reg¢ ic et issuance of. Rtawof_
Signature of Applicant Date
All roof coverings to be Class "B" or better
O arauthorimd cal Dom