05040080 CITY OF CUPERTINO ..e �'•� ' -'�'"`
BUILDING DIVISION PERMIT -.y;CATRACTURIN URMA`fIQN :.
Pe; 9.r WIZI
BUILDING ADDRESS: PERMIAN BUILDERS INC . PERMITNab5040080
ER'S NAME: PERMIT ISSUE DATE
AMES AVENUE ASSOCIATES
NE: SANITARY ND. CONTROL NO.
(510) 979-9081
ARCHITEC iENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
I� 0 0
Moo LICENSEDCONTRACTOR'SDECLARATION JobDescri tion
^� 1 bomby arinn that 1 am fthe D0 under Pmvisians of Chapter 9(on toting p
wed Section70(1))ofDivWon3ofmc Bualnw and Pro(rasiau Code.andm la
fl in full tame ane,Rat
�'�z uacnxc Clas Ix.g �8 O I--SPLIT CO Q� OFFICES
Dam c^numW NCLOSE BREAj 10Dk�L SERVER ROOM
0 ARCHITECI'SDECLARATION AAe ��t
� 1 undewnJ my phos dull W asst u puhlic oncnrN
3 ad LMeued Prorasalonal /t 2005
OWNER-BUILDER DECLARATION 6 s/ .sf
<E I hereby affirm o n 1 em exempt from the Cantrres Co :Any c Lew for the
O O fallowing Waren.ear,t ]11315.Butlanas and ere.demolish,
Code:Any city ser=lure
$�
which acquires a permit m ennurucL titer.improve,dcmnl13h,ee repair any atrvetum
prior m its issuance,elm mquises tie applicant far each permit W Ole ullned smumem
< that he is licensed pursuant W the pm,iM..of me Cm urecter'a U..law(Chapter 9 Sq.Ft. Vall�tiog0 7 5
FC9 (commencing with Section 7000)of Division 3 of tie Business and Professions Cade)or
3.. Net he Is exempt Ummrrom and the basis for the alleged exemption.Any violation of
Section 7031.5 by any applicant fora permit subjects the applicant to a civil penally of APN Number Occas pry'
not mart than five hundred dollars Occupancy p y + pe
0 Luawnvaftheproperty,army mploycan with waganuthetrmheompensadan, 31606033 . 00
will do the work,and mestructum is not ink^dedarafretW mrsaM(See.7044,Business
and Professions Code:TW Caamectar's License law doe,and apply W an owner of Required Inspections
property who buildsor improveadermn,and who clansmen week himselfor Waugh his
owaemployw,provided ren such Impmmmanta son not Intended aronmd forsale.if,
however,me Wilding or Improvement is mid within ove year of mmpledon.the ower.
builder will have the burden of proving that bo did not Wild or improve for purpose of
sale.).
❑1,as owner of the property,am exclusively contracting with licensed cantruWn be
construct the pmject(Sec.7014,Business and PrefaWans Cade:)The Contractors U.
came law doa ret apply W an awanr of property who Wilda or improvee meman,and.
who contracts far mch proi cez wim a contra mI.)licensed p.m m the Contractor'.
License Lew.
❑I am exempt under Sec. ,B&PCfarthlamuou
Date
WORKERS COMPENSATION DECLARATION
1 hereby effim under penalty of pedury aria of the following declmtio^s:
C 1 have and will mmol.•CenIDcate of Cement m self-lame for Warker'sCompcn-
udan,u provided for by Section 3700 of Ue labor Cade,for me performance of the
weak for which this Permit is Wood.
❑1 have and will maintain Worker's Compensation Insurance,u required by Section
01W of me Labor Cade,for me performance of me work la which this permit is Issued
My Worker' C�..sapm�3�eem�nutian Insurance canner and Policy number m:
tinier. �IVBN� Policy No.: t/
Pn
CERTIFICATE OF EKEMON FROM WORKER '
COMPENSATION INSURANCE '
Missectlnn need not W completed time permit Is forms,hundred dollen($101)
a Meal
1 certify that In the performance of me work for which 0113 Permit In Issued.l shall not
employ anypemon in my mannerm as W become subject to W Wmken'ComP,nsatian
Laws of California.Dam
Applicant
NOTICE TO APPLICANT:If.refer making this Certificate of Exemption.you mould
became$object m the Worker's Cm'sentimn provWuns of dee Lahee Code.you mus
.,O Forthwith comply wide mch provision or mis permit shell W domed revoked.
y CONSTRUCTION LENDING AGENCY
E~ Ihereby affirm met them is ecauwcUnn lending agency for the performance of
0.'> the work for which thin permit 13 issued(Sec.3097.Civ.C.)
G Q Lender's Name
Lender's Address
V Q 1 cctify not I have rad this application and sub that the,above Information Is
{i. Comm I gone W comply with all city and county o onto ers and state laws elating W
Q Wilding construction,and hemby authorize representatives of this city W edea uponW
W above-men0oned Nunnery for impenioa Purpoxs
G (boa)egrte a era,in ify rep hannksa W City of Npenino against
liabllitiu,Judgmcn sex d pe hick may In any way ecerve against said City
in Coneegannco f in f
APPLICANT D WIL OMPLY WITH ALL N N- NT Issued by: Date
SOURCE R NS.
7
SignatureRe-roofs
Ap c r Dec
H RDOUS MATERIALS DISCLOSURE Type of Roof
Will ma Lippliciltorfuume Wilding oaupent sae orhandic haurdeus material
u turned by W Cu nine Municipal Code,Chapter 9,11.amt tie Health and Safety
Schen 25532(a)? �<Nm
All roofs shall be inspected prior to any roofing material being installed.
❑Y,.
Will theapplicmt or future building eacupantme,equipmml ordevica which If a roof is installed without first obtaining an inspection,I agree to remove
emit lnuntous air contaminants u darned by the Bay Arta Air Quality Management all new materials for inspection.
DisvicR
❑Yea �Tiu
I h.rsadth mmimmunes un derChaptar6.93oftle Calif^r.
ride FMaIN&Safe 377 and133N.ImntW m
deuiltle Wilding
dean not c e mibllity W notary Ue aecupan of Um:
onquim h e ' rWkuumcofaCcnificaWofOc pa^aY' Signature of Applicant Date
Own r rsun n Date All roof coverings to be Class "B"or better