05070194Boz
yo
EU
`yon
C"
Ua
CITY OF CUPERTINO
�rvrrwl:aw= '-hpr ''>aa. "'�"Try�♦
�1..'
BUILDING DIVISION PERMIT
J,1C-1�g�V1�MAAV1VsA
BUILDING ADDRESS:
051 PARAn?-NA All
SILVER STAR DEVELOPMENT
PERMIT NOO 5070194
OWNER'S NAME:
PERMIT ISSUE DATE
CHURCH IN CUPERTINO
16294 RIDGE
2005
E:
SANITARY NO, CONTROL NO.
(408)399-7447
ARCHI7ECTIPNGINEER:
BUILDING PERMIT INFO
BLDG PLO MMH
O O
LICENSED CONTRACTOR'S DECLARATION
Job Description
1 hominy "an that I am Iiseosed i
under Provisions of Chapter 9 (Commend,
with Suction 7IXIU)afDlN. on Sof Ne Busioeu and Pro alum Code, and my 'ccnm is
lo"fora me ercea [
REVISION -RESIDENTIAL INSTALL NEW 1 1/2
Lkenan Clw Lk. a
Dam r1v_n��__nlcontrrnor
vis✓
TON HEAT PUMP -A/C PER NEW PLAN
DECLARATION
IN HOUSE ONLY -NO NEW PERMIT ORIG 03120043
ansGTRTECTS
I understand my plana shall the used as public rtenrtls
Licenced Professional
OWNER -BUILDER DECLARATION
I hereby a1fUm that I am Camara from the Conoacmr's License Law for the
following mumn. (Section 7031.5, Bush. and ProRWaas Code: Any city or only
which requires a Permit m ennsuuct. alms. Wprow, demolish, w repair my manctum
prior to its Issuance, Alm requires the applicant for such permit to file asigned ststemem
that Wis licensed pursuant to the provisions of the conaucmr's license Law(Chaptm9
Sq. Ft. Floor Area
Valuation
(commencing with Section 71XAB of Division 3 of the Business and Professions Cade) o,
$ 0
that W s emmpt Lh=fmm and die basis for the alleged esemption. Any viostian of
s'
APN Number
Occupancy
P y Ty�
section 7031.5 by any applicant for a permit ubjecs the Applicant to a civil penalty of
Out mom than 0w hundred dollars (5300).
0 L ac owner of the mepcoy, army employees with mg. As theirsak compensation,
Required Inspections
will do the work, and the A=mm is nut intended as@red for aces (Sec. 7044, Business
and Profeasmns Cade: The Conmcmr's License Law doss not apply to an owner or
property who builds aim noes lnemon.end whodoessuchworkhimself ardsough his
over cmploym s, pmNdcd thumb improvements art not Intended m offered forsak. if.
however, the building or improvement is mid within am year of compledan, the Owns.
Wilder will have the bunian of proving that he did not Wild Or Improve far purpose of
asm.).
❑ 1, as owner of the property, Am exclosively cunmcting with licensed conincmn to
7044, Cade:) The Contractor's L4
v�
If "/
convect We Farina (Sec. Business and protection
«sae Law dors not apply to an owner of property who Wilds or Wpmvas thereon, and
who Contracts for such projects with a conuanor(q licensed pursuant in the Contractor's
License law.
l
❑ Iamexemplundersoc. ,Bd:PCforthsmamn
Owner Data
WORKER'S COMPENS77IONDECLARATION
0^
1 hereby Affirm under penalty of perjury ane of the following Cambodians:
V
/J\
Ihave aha will msade.fartfe Waheface
salon, provided for mason 3700 of the labor Cade, for the performance or me
forbyn•CeNRasaf Lha Lm1 ofthe
r
wink for which this permit Is issued.
mi
❑ 1 haw and will maintain Worker's Compenaal insurance, a required by Section
3700 of the [Altar Code, for the performance of the work fa which this permitis inucc.
'
My Worker's Compensation In aces r and Policy number am:
r
tinier. Polity
C TIFI OF EXEMPTION FROMWORKERS'
COMPENSATIONINSURANCE
(Thismcdon need not Ac completed if the permit is for me headed densis (SIM)
.
or len.).--
.
I certify that In the performance of the work for which this permit is issued, l shall not
employ any person in my manner an as b become subject to site Worken' Compcmalon
Laws of Celiramia. Dam
Applicant
NOTICE TO APPLICANT: If, after making this CerMoam of Exemption, you should
become subject to the Worker's Compensation provisions of the labor Cade, you mum
forthwith Comply with such pmvsions or this Permit hall W deemed revoked.
CONSTRUCTION LENDING AGENCY
I hereby alfon that them Is construction lending.gcncy far the performance of
the wash fa which this permit Is issued (Sec. 3097, Co. C.)
Lender's Name
'
Lendces Add.
1 cenlfy mat I haw read this application and ass that the above InformNa is
COMM l Agra in Comply with all city and county c dinmcea and sus laws muting In
Wilding construction. and hereby authorise mpmsenmives of this city to enter upon the
above-mentioned property far inspection purposes
(We) agree to save, indemnify and tett, harmless, the City or Cupcnino against
Imbilitica.ledgmenu,cove and expenses which may in my way aarue against said City
inconumal. d
f th hat aSthis
APPLIe WILL CO WITH ALL NON -POINT
Issued by: Date
SOURC Ns.
Re -roofs
Roof
8-
Sig of AppllcanUC nor Dem
H MATERIALS DISCLOSURE
Type of
room nam m handle hasardous material
B the applicant ar fretum Wilding ecc
as etl the Cupertino Municipal Code, Chapur 9.Id, and Um Ncalth and Safety
hapt
cede,0zss3z(.)7
A. section
All roofs shall be inspected prior to any roofing material being installed.
Yo. o
If a roof is installed without first obtaining an inspection, I agree to remove
Will the applicant or bulleing Occupant um equipment or devices which
it hmre.. I, cwWnins. dellnedbythe Ray Area Amouality Management
all new materials for inspection,
Di'awl7
❑les No
I banal the nus riasmgetmmenmunderChapkr6.93ofthe Colder.
ns &Safety 505,25533and15534,1underesM thetifthe Wilding
dom n u a a nen, N I II s responsibility to nadl'y occupant of me
require which ren arm" afacenifa a may
ignature of Applicant Date
All roof coverings to be Class "B" or better
OwW4
as onaed agent// time,