051100322
BUILDING DIVISION PERMIT
GROSVENOR
1042
5110032
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COMPENSATION INSURANCE
Section need not becomplemd If the permit is f rruchundud dollen (SIM)
I cutify that in that perform, W the ooh fes which his Peron is issued, l "1 wt
employ any peran m ay maprcrse u m h=ome abject to the W^rted CMPMW.
Applicant
NOTICE TO APPLICANT: If, after maang ibis CeniRcam of Exemption, you should
b mesec subjm to he Wormej Compensation provisions of he Labor Code, you muss
forthwith comply with such providons or his permit "I the dwmed mwkod.
CONSTRUCTION LENDING AGENCY
1 hereby affirm hat hem IS a construction coding agency for the peparmanm of
he work for which this peri, Is Issued (S=. 7097, CIS. C.)
Lender's Nam:
Lendet's Address
I camify that 1 haw read this pplicWon and sum that the Show information is
Correct. l agree to comply with all city and county edimwu and cute lam MIWag m
building construction, and hereby ahodm Mpresenutiws of this city Le enter upon he
tosaw. IndemNfy and keep harmces Me City of Cupertino agdmt
W, cow and Cawwee which may in my my acerae agurest said City
WILL COMPLY WITH ALL NON -POINT I Issued by:
RDOUS MATERIALS DISCLOSURE
Nums building Omupwt erre or handle hamdom material
Municipal Cade. Chapter 9. 12, and the HOalh and Safety
r] Yes (:3 No
Will he applicant Or future building occupant ose equipment or device which
ccardans air eonumiwnu u deflnal by the Bay Arca Air Quality MMCCO n,
❑Yu C] No
I have mW he bwmthwS mamdals
S am" hu It IS my responsibility b ooury 0e occupant
a be met prior In bounce of a CwOum of occupancy,
Re -roofs
Type of Roof
Date
All roofs shall be inspected prior to any roofing material being installed.
If a roof is installed without first obtaining an inspection, I agree to remove
all new materials for inspection.
Signature of Applicant Date
All roof coverings to be Class "B" or better
(650)701-1500
ARCHriECTIENGINEER:
BUILDING PERMIT INFO
BLOC ELECT PLUMB MECH
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LICENSED CONTRACTOR'S DECLARATION
Job Description
I thereby eby athat 1 am Ikaved under Pmvidans of Chapter 9 (....act.,P
with smaon 70M) of Division 7 of W Business and PMOSSIMns Code. and MY li=me Is
hfunfame.ndefr
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ARCHITECTS DECLARATION
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1 wdouunJ my plans a1Wl bu used u public records
Licensed Professional
OWNER -BUILDER ON
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1 hereby .Ilii 1 am escmpt from ho CanlremCo License Lew for the
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following moon. on ns Code: Any city or county
7071.3, Bualn^u and Rd.
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$40005
IRR
R
emtion
dem aumure
which regulm a permit fe wnaue4 pain bnpow, demolish. m
!VN
Al
e a sir ed
pear m its co, calm rt Me dm spplkwt far SuchCam pcmrt m 0c a tiLaw mamment
of NeCwummasaic^u:isws;
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Valuation
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licensed to Dishes
putbubwith Code) w
f Division r Code) Or
mfAny
70M)and
Mf
Snuu,ahc of of al egad m pdnd
(commencingaIseempt Section
vi
that io b exempt A" Apr li and hn aura far be alleged esemant M Any violation of
S f
Section 7071.E by huy Applicant fora perk abjema he applicant m a civil penalty of
,
r
-� Occupancy Type
not mom than fin hundred da1Wa (fSWi
❑ 1, u awns of hn pmpaty. w my mploym wW mgca u thekwb campemdon,
wifl othewOrkmddmauu=umbwtinzn wonemdforsde(Sw.ri .Budr...
Required Inspections
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and Profeaiamam CaThe Commutes Licerm, law dm ml apply man Owner a
property be bulldaorimprowa hemon, andwMdoeuuchwork h mseffw duaaN his
Own employer, provided than Such Impmwmema art not intended ora@rod forssle. U.
hamver, the building or Improwneent is sold within wen year of mmpledan, the omer-
bullder will have he burden of prodng that M did and build car Improve for purpose of
ssc.).
❑ i, u owwr of the property am uelupvely eonuaeting with Icenved mnaamlt m
cancer the project (SOC 7044. Budwss and professions Cade:) The Comraemts U.
ceom law dm oro appy m an awtser of property -'bo builds or impmvn hereon. and .
who manna for Such pokes with a contramons) licensed purattanl rhe COMrseteYa
License Law.
❑ Im womptunder See ,B d P C few this recon
WORKERS COMPENSATION DECLARATION
1 herby affirm under penalty o(perjury ow arm the following daiuWm r
w and will mdmaM a certificate of consent to self-inam res Wahefa Cmnpen.
IMyData
uprovided far by Section 3700 of the Labor Code, far the pdomance Of he
ar which Nis pmnk is issued.
aw and will maintain Worimes Compensation houranm, u required by SeNon
f dm Labor Code, far he performance of W work for which aids Amit b issueddte's
ComPwtion I^mm card= W Policy number ate: ,
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COMPENSATION INSURANCE
Section need not becomplemd If the permit is f rruchundud dollen (SIM)
I cutify that in that perform, W the ooh fes which his Peron is issued, l "1 wt
employ any peran m ay maprcrse u m h=ome abject to the W^rted CMPMW.
Applicant
NOTICE TO APPLICANT: If, after maang ibis CeniRcam of Exemption, you should
b mesec subjm to he Wormej Compensation provisions of he Labor Code, you muss
forthwith comply with such providons or his permit "I the dwmed mwkod.
CONSTRUCTION LENDING AGENCY
1 hereby affirm hat hem IS a construction coding agency for the peparmanm of
he work for which this peri, Is Issued (S=. 7097, CIS. C.)
Lender's Nam:
Lendet's Address
I camify that 1 haw read this pplicWon and sum that the Show information is
Correct. l agree to comply with all city and county edimwu and cute lam MIWag m
building construction, and hereby ahodm Mpresenutiws of this city Le enter upon he
tosaw. IndemNfy and keep harmces Me City of Cupertino agdmt
W, cow and Cawwee which may in my my acerae agurest said City
WILL COMPLY WITH ALL NON -POINT I Issued by:
RDOUS MATERIALS DISCLOSURE
Nums building Omupwt erre or handle hamdom material
Municipal Cade. Chapter 9. 12, and the HOalh and Safety
r] Yes (:3 No
Will he applicant Or future building occupant ose equipment or device which
ccardans air eonumiwnu u deflnal by the Bay Arca Air Quality MMCCO n,
❑Yu C] No
I have mW he bwmthwS mamdals
S am" hu It IS my responsibility b ooury 0e occupant
a be met prior In bounce of a CwOum of occupancy,
Re -roofs
Type of Roof
Date
All roofs shall be inspected prior to any roofing material being installed.
If a roof is installed without first obtaining an inspection, I agree to remove
all new materials for inspection.
Signature of Applicant Date
All roof coverings to be Class "B" or better