05050102 CITY OF CUPERTINO xbI 7c �@'* 10 c�'P.�x' %"-+
BUILDING DIVISION PERMIT U1.vT,RAC.�TORAINFORMATION"
a ..4— '003F"".. ._
BUILOINGADDRESS: PERMIAN BUILDERS INC. PEB""050501O2
OWN0-n DgI.WERID99 AVE # 100
ER'S NAME: PERMIT ISSUE DATE
E: SANITARY C N.kl.NO.
ARCHITECffENGINEER: BUILDING PERMIT INFO
BLDG ELECT' PLUMB MECH
+hoz LICENSED CONTRACTOR'S DECLARATION Job Description
I hereby affirm that 1 Am licensed Arae,provialans of m
Chapter 9(wo cnchu p
with Sect¢70(10)af al 3 of the Butlrcsaand Ptufurans Cade.and my license is
In fail sac and ctteck 5462130
5'�: Liea.ac Lk.. REVISION--ADD INTER. OFFICES
_ � D.Cie mer NO NEW PERMIT ISSUED/ ORIG. #05040080
9 ARCHITECTS DECLARATION
�i I understand my plans.hall W used As public records
0
30
Licensed Pmleai...I
OWNER-BUILDER DECLARATION
f 1 hereby Mirea that I Am exempt from the Comraemh License Law for IM
o O following mason.(Satan 703 1.5,Business and Pmfesduns Code:Any city of county
which requires a permit to consuvct.Aber,Improve,demolish.or repair my structure
prior to its issuance,also requites the applicant for such permit to rile a signed moment
C that he is licensed purmam to the provision of the Connector's License Law(Chapter 9 Sq.Ft. Floor Area Valuation$35
$ (commencing with Sudan 7000)of Division 3 of the Business and Professions Cock)or Y
.,han esempt thcmfmm and the buds for the alleged emmption.My violation of
Section 7031.3 by any applicant for A permit subjects the applicant At a civil penally of APN Number Occupancy e
not mart the five hundred dalim($300). p y Typ
❑1,u owar ofthe property,army employees with wages as thehmlecmnpensation. 31606033 . 00
will do the work and the stumurt is notimended araffereE fonak(Sec.7044,Business Required Inspections
and P.I.W..Code:The Conummrs License Law dos set apply a an owne nser of q p
property who Wildai orimpmwa thereon,andwhodoessuchwuk hlnualfortuough his
own employees,pmvidcd Nat such Improvements arc not Intended or offered forms.IL
however,the Wilding or Improvement is said within arc)ear of completion.the owner.
builder will haw the burden of preving that An did not Wild a improve for purpose of -
Ad..).
❑1,As owner of ct Sec.7044,
property.am Bane si And contrasting with Bcemed cmntrman t.
"AsoconstLaw
the project apply
in0 n ownBuser
of and property
who Wilds
Cotler)The Conuacm,i Li-
who law deer not apply je an owner of property wce Wilds or improv Cornton.and
whonseLa.for such projects with seam,¢tor(s)Ilcenad pursuant in the Contractor's \
License law.
❑1 am exempt unOu Sec. .B d:P C(sur Nb recon
Owner Date
WORKER'S COMPENSATION DECLARATION
I hereby aflhen under penalty of perjury am of the following daluedou
ham and will maintain aCeNOmte of Consent to alf-Insum fm WwkeriCompan-
a on.As provided far by Section 37M of the Labor Code,fm the performance of to
work far which this permit is issued.
❑1 haw and will maintain Worker'sCompensation Insurance,as required by Section
3700 of the Labor Code.for dte performance of the work for which this Permit is Intend.
My Worker's(C�ompe cation Insurance artier and Policy number art:
Canner. K at�l1(;l-tL PalicyNo.: Dr7b@.�5-I
CELE IFICT�OFEREMPIIONFROM WORKERS'
COMPENSATION INSURANCE
(Tbb section need rat W completed if Its Permit Isfarone hundred doll 100)
or Ica.)
1 certify the,in the PerformaAe of the ark for whj i s
cmployanypcnoninany 1 v8albma b r parried.
Laws of Celifomla.Dass llJ
Appllmnt
NO77CE 7D APPLICANT:If.after making thl cni0c c prion.you d
become wbjen m the wortets Compensation proviaioro aft 4bor Cade,You mu
,JO forthwith comply with such provision w this permll shall eemed mvokud.
r 0 CONSTRUCTION LENDING A NCY
F" l hereby attum Nat dart is a consuactinn lending agency for the Performance of
14� the work for which this permit Is Wood(Sec.3097.Civ.C.)
W Q Lender',Nene
�2 Lender'.Address
V 0 I canify that I have mad this application And tate that Ne chow Information a
L,v coma 1.Ince At comply with W city ad county ordinances and sole laws minting to
0 building conswction,and hereby.uthodre mpmsenatives of Ni.city to enter upon the
W ahve-mendaned ptapsny for lnspeWm purposes.
(We)agree Io mw,indemnify and keep hanmlem the City of Cupertino against
a fn Iiabllidq,judgments,cubo and expenaa which may in my way seems Against said City
In consequence afthe Standing of this permit.
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT Issued by: Date
SOURCE REGULATIONS.
Re-roofs -f
signuurt afApplicaData
HAZARDOUS
S Wilding
MATERIALSDISCLOSUREType of Roof
Will the Applicant or future Wilding=upset,Chpt ram sur handle Health an material
As defined by the Cupenina Municipal Code.Chapter 9.13,and the Health and Salcry'
Code.S.A.W32u)7 All roofs shall be inspected prior to any roofing material being installed.
❑Yen I(No
Will the applicant or future Wilding occupant sea equipment or devices which If a roof is installed without first obtaining an inspection,I agree to remove
I havadnu air co ami oma u defined by the Bay Ara Air Quality Management all new materials for inspection.
strim7
QYes 1Io
Miff
quimmenu under Chapter 6.93 of the Califor.
A.
H333 aW 21334.1 unhrrva thrifiM bonding
Ores y rupuiMlity a wuly to occupml of the
rcqui manceofacenifmain roc cu cy. O Signature of Applicant Date
ownar m mthmixaa ent IDA All roof coverings to be Class"B"or better