05090071CITY OF CUPERTINO
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BUILDING DIVISION PERMIT
BUILDING ADDRESS:
PERMIAN BUILDERS INC.
PERMIT"°'05090071
19050 PRUNERIDGE AVE
OWNER'S NAME:
PERMIT ISSUE DATE
AMES AVE ASSOCIATION
4125 CLIPPER CT
09/16/2005
E:
SANITARY N0, CONTROL NO.
(510)979-9081
ARCHITECT/ENGINEER:
BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
LICENSED CONTRACTOR'S DECLARATION
lob Description
I hereby afthm that I am licensed under provisions or Chapkr 9 (commencing
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with Section 7") of Divixion J mNo Bummer and Profcasions Cade, and my license Is
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TI -ADD LOBBY/CONF RM/BREAK/COPY &
Lie.
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STORAGE/SERVER/NO DEMO, H/C TO CODE
�K A�I7FCI'SDECLARATION
I unMruand my pons shall W used as public commas
Licensed Perfcuional
OWNER -BUILDER DECLARATION
I hcmby affirm that I am exempt From the Centimeters License Law for the
following reason. (Section 7851.5, Business and Profusions Code: My city or county
which requires a pemtit to construct, aloe Improve, demaleb. or repair any structure
prior m its issuance. also, requires the applicant for such permit to file a signed stamment
Nat he b 1wensod pursuant to the provisions of the CmUserne. Lkrense Law (chapter 9
Sq. Ft. Floor Area
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(commencing with Section 7000) of Division 7 of the Bminex and Pmeulans Codd) or
that he b exempt therefrom and the basis for the alleged exemption. My violation of
k er
Occupancy Type
section 7031.5 by any applicant fora permit subjects the applicant to a civil penally of
not more than five hundred authors (Mx
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310V,
❑ I, u owner of the property, or my employees with wages as Neth sale compecssdon,
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UII'ed°I'a ecIioNSR
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will do the wmkand the awcmm beat Intended., offered for saw (Sm. 7044, Businm
and Proletarians Code: The Canmem's Lures law dam not apply to M owner of
propertywho Wlldsorlmprovellrtm.mond whadaaauch work himselfortmouN his
ownemployees, provided Outeachimpm"+ uarenotinmMedmafferedfmuk, If.
however. the building or Improvement is sold within ane year of completion. the mveer-
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builder will Mw the burden of proving that he did net Wild or improve fm se purpoof
oak.).
❑ 1, as mvncr of the property, am exclusively convecting with licensed contraction; to
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consumer the project (Sec. 7010, Business and ProWsiou Code:) The Contractor's U.
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ranee Law does not apply ut an owner of property who Wilds or improve thereon, and
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who convaco forsmh projero with a contractor(s) licemulpemuam to she Contractor's
License Law.
❑ I am exempt under Sets. . B & P C fm this moon
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WORKERS COMPENSATION DECLARATION
I hcmby a01rm under penalty of perjury ane of we following declarations:,
1 Nve and will man Wna Cort of Consent to self -Wore fm Worker's Compcn.
"do., u provided Re by Section 37M of the LaWr Cade. rat One perfo marten of ft
work for which this permit is Issued,
❑ 1 have and will mountain Worker's Compensation Insurance, as required by Section
57W of the Labor Code. for the performance offs work forwhich this permit is issued.
My Worker, Coope don Imrnmvartier and Policy number art:�{�
Cartier. LL%'W policypolicyNo.: JM �s404A
EROPICATE OF EKEMPIION FROM WORKERS'
COMPENSATION INSURANCE
(Hub section need not W completod lithe fourth Is foroac hundred dallae (11100)
sir leu )
I certify that In the performance of we work for which this permll b issued, l shut not
employ any persen in any manner anis in became subject to we Workers' Compensation
Laws of CW (omnia. Dam
Applicant
NOTICE TO APPLICANT: If. a(mr making this Gafford of Exemption, you shauN
become subject m the Worker's Compensation provisions of the Labor Cede, you mum
forthwith comply with such provision or this permit Nell he deemed rtvaked.
CONSTRUCTION LENDING AGENCY
I hereby affirm that fort ba conmructinn lending agency, for we performan¢ of
the work for which thb permit It Island (Sec. 3097, Civ. Q
'
Lender's Name
,
Lender's Md.
1 really Nat 1 have word this application and sum that the alove information la
cancer. 1 agree 0 comply with all city and county mainances and sum laws relating ur
Wilding construction, and Mouthy saturnine rtprtxntstive of this city m ensu upon the
aWve-mentiomd property fm inspection purposes
(We) agree to save, Indemnify and keep harmless, the City of Cupeaiao against
liabilities, Judgments, tato and experou which may In my way acrnm against Wd City
in consequence of the grana ng of this permit.
APPLICANT NDERSTANDS AND WILL COMPLY WITH L ON -POINT
Issued by:9 Date
SOURC ORIS.
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Re -roofs
Type of Roof
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HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or forum Wilding mcupantmore or Media hassrdaus material
as defined by the Cupertino Mumcip 1 Code. Chamer 9.12. and the Health and Safety
code. Section 255314)7
All roofs shall be inspected prior to any roofing material being installed.
❑Ya VC
If a roof is installed without first obtaining an inspection, I agree to remove
Will the applicator or furore Welding 0aupam use equipment or device, which
t h®ar sees air eonuminants as defined by the Bay Area Air Quality Management
all new materials for inspection.
District? /
❑Yes &We
I haw mad the haramrms memualarequimmenu um4r Chapor6.95 orthe Califon
nice Health &SifmyCadc, Sections 25305,255334nd 25551.1urematand thatiffm Wilding
dote not currently ham a M.Nt, that II Is my respom@ility us aoffy we occupant of the
requirements which muss W Ipriereassuanccefacenificate of/p .
Signature of Applicant Date
All roof coverings to be Class "B" or better a
owns ora .rxeds em Dam