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CITY OF CUPERTINO - -
CONTRACTOR INFORMATION:
'
BUILDING DIVISION PERMIT
I BUILDING ADDRESS:
1 2. 'U" . ' .. ,.
PERMIT NO. _
#4, RESULTS WAY
01,060102.••;
„.
,,. -•,:,i',
-OWNERIS'NAME:—"'_.""-""•"•�.-^-+,-'-•..—.-.--_..__...-_,--,..,.
...
...-.__. _-_.._... __.-.._.._...._... _._, -,.-...._......APPLICATION
SUB DATE.__. ___,..--.,..... _,-..__...._
INSIGNIA PROPERTIES
06/18/2001
PHONE:
SANITARY NO. CONTROL NO.
Z ARCHITECT/ENGINEER:
BUILDING PERMIT INFO
pD
BLDG ELECT PLUMB MECH
I__J �I
c LICENSED CONTRACTOR'S DECLARATION
Job Description '
Ihertby affirm that)am licensed under provisions of Chapter 9(romYectut.
w with ScI herby affix thatIoam ofshc Businessmd Pion so sCWe. (tom license
is in full force and effor '�_'V'
SIGHT SCREEN REPLACEMENT.
icon lass Lia a b Z
Dae o so aamflOr
ARCHITECT'S DECLARATI N
g I understand my plans shall be used as public rt� s .
Olactose! Pnimioli nil
tats, OWNER -BUILDER DECLARATION
-
1 hereby nfnan that) in exempt from the Conuamor's License Law for the
s' following reran. (Section ]031.5. Business and Pmfessiom CWe: Any city m county
$51000 ' . ..
C which requires u permit m construct. alter ,improve, demolish, or more any structure
pro to ts'. eq also 9 ith ,lila mru hpe o fl g Wav ns
.. _
- - - - --
_ 1 f U( aarea r
3;]%f, 4'i
Valuation
that he {1' s I) t. n d psv tam uleC t r L I-,,, Chapter9
(Zit , ng wsh Seslan 7000) of Division 3st the Btraim ndPalas ono CW[)
`'s , 4V': -x1t x
nr main, to exempt Immomo and the basis Tnr the all[g[d ehemp,iah. Any violation
-
-
-m second 7031 s by any appdcam for a pemtn,objects the apprcam m acivil penalty
of not mo than rive hundred dollars asool.
_
516APN' t� BUI LD I N
�Qccupancy Type
� -_
o • ❑ Lasovaberortim ropety.m., employees with wages as their sale compensation,
-'will do the'wmk; and the smuctum is' ordLimended' or oRemd for sals'(Sec: 9044.
'Bd.iMa.
corner of property Who builds or improves thereon, and who does such work himself
_ - -
- or through his own i employees. provided Ilia such improvements art nos amended or-
..-dRercl intrude lf.lima .O building -p t' Ycara
xold�wnhnand f
omplei on the owner builder will have the burden of proving that he did rot halm or
improve for purpose of sale.).
"co L owner.pr Ne property, um exclusively with lion
•'
onswn the project (Sec. 9tsla, Business and role si CWe:1 Thcnmmaats Contractor S
to d Professions
wsioos
Litems law does apply n property improves remi.
wrcr or property who builds m improves tM1in
etre
and alio contracts focsvch pmjecs wiN a.commesorsx)_licensed Pursuant m the
.f pro
Comracmrs License Law.
❑lam exempt under Scc-r'_ _ 'IB&PC for this neaten
rr
-F�NqLE®
Own 'Date `
WORKER'S COMPENSATION DECLARATION
SEP i 0 -
' Ihereby affro, under ofperjurytior.!hefollowing decliations.
2001
penalty
❑ 1 have . will iniumi iri a 6enificam of Conant io elf -insane Tor WOIXer s
,
_ Cnmpen.aron. as provided for by Section 3900 or the labor Code. for tae
BUILDING
perfommace a the work for which this permit is i ... or
_
❑ I have ad will maintain Workers Compenaaion I.oronce, as required by Section
pe pe
37001 of he L b Code. f 'the formun a of the work f h h IIs
' issued MY rk 's C J 1 Y e:
4a9 d Pol c n be
/ / l/(
�O/ r,/
Carrier r is.1my No,s
-
to CERTIFICATIONOFEXEM"lI FROM,WORKERS,,-
' `;' COMPENSATION INSURANCEu: ""' - ' -
- - -
` '•iihis'seeninti httJ nos becompleted if the permit is for one hundred dollars
•Y•Nvar' - .is s, s r it
'
(SWO) or less.) . :...
.. _.
' 1 cemfy than n f the aark force h Ilii mus is iW.mc1 1
.. _ .,., ..
any mami ct
employ any pawn m any manner w as m become subject to the Workers
'hall eroin
.... .. ' . .
-• - -
CnmpanntianLaws ofCalifornia .Date ' ''
Conni r
--
. --Applicant . ' ' _. ._.. - .. .:. _ .. . _-
.. - ...___._.... _._.. ..... _- _. -. .-.. _ .. .. _. ..... -
NOTICE TO APPLICANT: It. after an.ong ,his CeniOcmc of Exemption, you should
bets ,.bjemmthe Workers Coinpenmtionpmvisionsofthe LSlwrCWe.yora must
forthwith comply with such provisions m ,his permit shall be domed revokes.
ti • `` to •" 1 CONSTRUCTION LENDING AGENCY -
afrrm that then is a construction lending agency for the lierformance
Ihertb.3
t -
., Or the work for which this penia is issued (Sec 1U91. Cr,. C.)
.. ..... .. ..... ....
Lender'sN:ime..-, ra. __,•..-,��... .... ax._, _.. ....._. .., .. ....
_ __.. __.. ., _.. _. ....... _.. _.-._.._ .. .. ..... ....
Lender's Address '
J .
„ 1 centfy that I have d th ppir ton and nate that she W information is
o er 1 g so comply with 11 city a J ry N' arc a d state la s Mating
j tolnuildabo g construction. ndh by authorizep hive fnh.cyt enter upon
k1 the bo t nedpropenderminPea nWrq.
y (We) agree keep the City (Cp ono ago inset,
eci andexpeznd
which.moy in any way umrue against said
n liabilities, judgments, coos :ted expenses which in
-,
i 0O
L chyA[pnse UND m the gDSANter ink,permitPL° '
•[1PPI-ICANT UNULsi1 TAND9 AND WILL COMPLY WITfi ALL NDN-POINT"t
';' ��t •�'
Issued by: Date
bo��c��Ns. t
-' Bflwwrc o> - Dam:...
I,}s'•
Re -roofs '
HA2ARDOUS'b1ATERIALSDISCLOSURE 'c
HAZARrdcmr_,. SCL
_ willytapplicant m future handle
and Surnalafety'
Type Of Roof .. ---'-'^-.----'- -- --._...'.- •
MunicipatCode. Chaptr91Or
Health
define) by the Cupertino hI'.. poi Code. Chapter 9.12, and she Hcahh and Safety
'Citic
,
C Sc a 25573(1 '. f .•
❑r r-', ❑Ivo'.
.: ..
All, roofs, shalL.be.inspected.prior,to any,. roofing material being.installed.__,_. ..-,
i ,Will theu pr[ t r brim's p , aq pre desire, which,
em t to N [ant t. defined by theB Area A' Quality Management
If a roof is installed without first obtaining an mspectlon;'I agree to remove
for,inspection. 'Applicant understands and will comply with
District' ,
ore' , ' onm' l _ _ p ;
all new materials
_-all non -point source regulations...,.. _ .^
-' I have read the hdxamina, -materials requiremems under Chapter 6.95 of Ne'
California Health& Surer, CWC Sections 25505, 25533 and 25534. 1 understand that)
if the building does not currently have a tenant, ,hat it is my msponsibility to notiry the;
.occupant ofthc mquir tens which most he met prior to issuance of a Cenif,uste of
• O /
Si nature of Applicant ate
- _ .. .. ..-
All roof coverings to be Class "B" or better
nrhnrixedagent-'Date
.Ownerar
..:.. .._._ ... - OFFICE