05030166 CITY OF CUPERTINO
BUILDING DIVISION PERMIT ,CONTRA.CTOIt=IN1H'O,'LtMA' ,O :
t "°z-,$-"� '.
DING ADDRESS: NOVO CONSTRUCTION PERMIT'%5030166
ER'S NAME: PERMIT ISSUE DATE
GROSVEN R
PHONE: SANITARY NO, CONTROL NO.
(650) 701-1500
ARCHITECTIENGINEER
50 701-
ARCHITECTIENGINEER: BUILDING PERMIT INFO
BLDG 0 PLUMB MECH O
�Op LICENSED CONTRACTOR'S DECLARATION Job Description
I hereby affirm that 1 Am licenced under Provisions of Chapter 9(commencing
with Section 7011)of Division 3 ofthe Business and Professions Code,and my licenss 4
'o❑ infull msasndercmL �9/O� REVISION-UL LISTING FOR 2 HOUR
5 Z LICenc Clete LIC.,
Dem - contractor • •oPASSAGEWAY
ARCHITECTS DECLARATION
s� I u chratand my plans shall W used As public records
is Licensed PoulnManal
ss Oat I Am exempt
from
DECLARATION
+� y I hereby.(lien that 11.aempt from tin essions CO :License Law for dm
o D following moon.permit
t 710 L4 Business and e,de soli Code:My oily m county
$� which requires•pnmit m construct inter.Improve,demolish,or repair any simuue
is prior to its issuance,also requires the applicant for such permit m rile a signed auumenl
< Nat be is licensed pursuant m the provision of the Contractors Liare Law(Chapter 9 Sq.Ft. Floor Area VHIUHG Ol1p 00
zC$ lectern rein,with Sallon7(X0)of DiWion 3 ofdm Business And Profession Coda)or
3
that he 6 exampt thrtfmm and We basis fm Use alleged emmpuon.My Noladan of
Section
t
noan.Nan fl.Mdrtdidnt for
aper7it subjects Oc applicant to a avil penalty of APN Number Occupancy Type
01,as owner of the property,Or my employees with wages as Web role compenadon, 35720042 . 00
will do the wv*.and the structure 4 not intended.offered for We(Sao.70th.Business Required Inspections
and Profession Cade:The Contmvrs License Law don roe nst apply W an owner of q p
property who buildsorimposes demon,andwM dasaah wink himselforihmugh his ,y
own employees,provided that such improvements Are notlnunded araffeted for sale.If,
however,the building or Improvement Is sold within one year of completion.the owner.
builder wIE have We burden of proving that he did not Wild an Improve for purpose of
sale.).
❑
I.as owner of the property,am exclusively contracting with licensed cuntramrs to \
construct the pmject(Ser.7014.Business and Profession Code:)The Conishaors Li.
cert Law don not apply to an owner of property who Wilds or improm thereon,and
ccomets for such pmjecu with a contracOt(0 licensed pursuant to the Contractor's
Law.
A
esempt undo Sec. .B&P C far Ois reagin
r Data
WORKER'S COMPENSATION DECLARATION
I hereby atfirm under perulty,of perjury one of the following declatadon
1 haw aM will msinuin•Cenifirmeof Covent m rel6inure for Worker's Compm-
saoan,u provided for by Section 3700 of the Labor Cade,for the performance of the
work for which this permit is issued.
❑I have and will maintain Workers Compensation Insurance,as inquired by Section
311of the Labor Code.for dm performance of the work for which this permit is issued.
My Workers Compensation Insurance artier and Policy number ere:
Cattier, Policy No.:
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE .
mus seedon need nottxc npleud ifdw permit Isforone hundred dellata(510(11
or ins.)
1 comfy that In the performance of the work for which this penult is issued,I shell not
employ any person in any manner sat As as become subject to the Worhen'Compensation
Laws of California.Dau
Applicant
NOTICE TO APPLICANT.IL after making this Continue of Exemption,you Would
become subject W the Workers Compensation provisions of the Isba Code.you mug
O forthwith comply with such provisions at this permit shall be m
deeed revoked.
z CONSTRUCTION LENDING AGENCY
(-, I bereby a from that then sae conuucdnn lending agency for dm performanCe of
ai> the work for which this permit is Wad(Ser.3097,Civ.C.)
W�Q Lenders Name
i7. z Lender's Address
(.3 Q I Certify that 1 love rust this application and sum that rite aWn information is
LI.^ coma 1.gra to comply with all city and county ordinances and sum laws relating W
Q`rJ' building construction.and hereby wthotie mptesommim of this city to enter upon We
ill above-m adoomd pmperty for inspection purposes.
0. (We)agree to save.Indemnify And kap harmless the City of Cupertino agaWt
V LI
rrA lmoilumajudgmenuaccrueag
,costs and expenses which may in my way accrue Using said City
APPLICANT uence Of LW RI
ANTUNDERSTANDSANDS ANOf this D WILL COMPLY WITH ALL NON-POINT Issued by: Date
SO RCE REGULA
MAS neck �� 3�17�oS Re-roofs
-�me of ApplicaMCantralar Dam
HAZARDOUS MATERIALS DISCLOSURE Type of Roof
Will the applicant or future building oecupanlgore or handle hazardous m ucrial
6
c0net by the Cupertino Municipal Code,Chapter 9.13.and Oto Healthand Safety
A.Salton 25533(a)1 All roofs shall be inspected prior to any roofing material being installed.
❑Yu RRO
Will due Applicant or future Wilding occupant sex equipment at devices which If a roof is installed without first obtaining an inspection,I agree to remove
omit Maroon air cauumironu As dofined by dm Bay Area Air Quality Manapcmcnt all new materials for inspection.
DimnctT
❑Yes
1 haw mad the h.AM.' dAiSmquimmcnuunderCMpter 6.95ofrite Califon
nu Health&SafmyCode,Scctims25305.25533 and 25534.1undcm ool thatifthe Wilding
does not currently hew a mnam,Oat It is my responsibility m notify de Occupant of Oe
requirements which must be met pdu ht Issuance ofa Certificate of Occupancy. Signature Of Applicant Date
All roof coverings to be Class"B"or better
water a wthonved gcnl Dam