04090081 CITY OF CUPERTINO �nx� ^ q�� '9 '3i ♦.x. �` �,
BUILDING DIVISION PI✓+RMIT 'xC�L\ 1[1iC
BUIIDINGADDRESS: SKANSKA USA BUILDING INC PERMIT ND04090081
ER'S NAME: PERMITISSUEDATE
12004
NE: SANITARY O. CONTROL NO.
(404) 511 -4496
ARCHITELTIENGINEER: BUIIDINO PERMIT INFO
BLDG ELECT PLUMB MECH
=
+ioz LICENSED CONTRACTOR'S DECLARATION IobDeSGrI Description
I ameby afror Nat 1 nn Iimrred un r prev.. of ChaPmr 9(commencing p
withseaIlon7=)Of Division3ofthoB .,W- sslons Cade.md ylicenmis
mmRfolRandtuex / TI--INTER. DEMO/PARTION WALL/RATED COORIDOR
5j'3 Lee. Uc.M
Date Can
�i I u nJ mARDECLARATION
yplanshall b used
as public recnms
3 s� Licensed Professional
^ OWNER-BUILDER DECLARATION
d-'x I home,alllrm that I am eacmpt from the Canlwctars Lieenm law(at Inc
p o following mean.(Section 703 1.5,Business and Professions Cole:Any city or county
$ which requires a permit to e mRum.after.narrow.demolish.or repair my nmctum
primo its issuance.also mquima the applicant for such Permit to file a signed sutemenl
G that W u licensed pomant to the previsions Of the Commutes Lee..Law(Chapter 9 Sq.Ft.Floor Area a UBCIOn
$ (commencing with Sudan 7000)of Division 3 of Ne Businasaand Pro(esamn,Code)or
Net he'In exempt thwefmm and tht basis for eve alleged exemption.Any violation of
Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of 31ARV V"M 0 Occupancy Type
Out mom than raw hundred dollars(SSW).
❑Lasowllm Of the themm,mmy wpleym withwgtsas is(Sec.nemBecomes
will Pr thcwms and the ase Coohnati Livenstended Law
!mot apply 71144,owmae Required Inspections
and property who
Code:The wsthe ton. ad me Law dace not apply lf an owner of q p
propertywho battles oricemavas hhoon,andwhosaessuch wart mattered
his
Own employtWiprovided thatouchimpmwmenthin not earm'cntpitu m.fm deka If.
Wilder the buildingorimprovement is mrd withinone)w of mproe for purpose will haw the Wmm of proving than he sits not build or improve far puryoxe Of
Sale.).
❑1,as Owner of the property.am exclusively coawning with licensed conuanms to
mnstmm the project(Sea 70th,Business and Pmfe.,i.Cade:)The Correctors Li.
mesa saw docs not apply 0 an owner of pmpeny who builds or improvers thcmen.and,
who contracts for such projects with a cbnracmr(0 licensed pursuant M the Contractors
Licanse Law. �J
❑Ion eacreptunde'Sea .Bh PCfm Niarmmn
or Data
WORKPR'S COMPENSATION DECLARATION :
1 hemby affirm under penalty of perjury oro create declarations:
declions:
❑1 haw and will maintain aCeNOcae of Cement to ul6imum for Work sCompcm
niton,as provided for by Section 3700 of the Labor Code,for the peAum
ame of the
work for which Nr permit is issued.
❑1 haof tm and will maintain Workers Compeesadan Imran.,as required by Secdon
371 he labor Code.for tht performance club,wars fmwidCh this permit is issued.
11
ng a. of
licy
a Worker PeCA1 � EMePnON FROM WORKERS'
U COMPENSATION INSURANCE
(This moan need not W completed I(Ne permit 1.format hundred dollars(SIM)
or li
1 warily that in one performance of One work fm which this permit is Wood.l shall not
employ any person in my manner an as to become subject to the Workmi CompemNan
Laws of California.Dau
Applicant
NOTICE TO APPLICANT:IL after making this Cc tiOeare of Exemption,you should
become Subject u the Worker's Compression on pmvisions of the Labor Cade.you most
O faMwiN comply with such prvisinru m this Poirot pershall W deemed reveled.
„Z-,y CONSTRUCTION LENDING AGENCY
(••,..w I bemby affirm that Nem is a construction lexim,agermy far lM aformanmuf
llir
the work far which Nu pemril is Wood(Sec.3097,Civ,Cd
W� Lender's Nam.
] Z fender's Address
U0 I modify Nn t have read Nb application and sum that IM show Information is
V.F context.14.to comply with all city and county ordinances and sane laws muting u
DU building construction,and hereby audlodw representatives offas city to enter upon de
tU abovmmendoned property for lnspeNon purposes.
(We)agree w saw,indemnify and keep harmless IN City of Cupertino against /
y liabilities.judgments,toss and expenses which may in my way+erne against Said City
in U 7 APon toNDERhis permit.
STtINDSIANO WILL COMPLY WITH ALL ONP INT Issued by: Date
F7 ULAT /
t{rtofe ApplicanURe-roofs
Comrs Da
HAZAR S MATERIALS DISCLOSURE Type of Roof
Will the applicant or(uuma building occupant atom Or handle hvamous material
dcOmd by the Cupertino Municipal Code.Chapter 9.13.and the Health and Safely
Section 25532(.)? www���////// All roofs shall be inspected prior to any roofing material being installed.
0Ym IpNo
Will the applicant or future building reception use equipment or dcviws which
If a roof is installed without first obtaining an inspection,I agree to remove
emit hvsrdnm air conuminsnr as dcfinsd by the Bay Arta Air Quality Mar l4ceaml all new materials for inspection.
❑Yee No
I have read the h t andommmmerubmquimmenu under Chapter6.95 ofthc Califor.
ala Health k SafcryCo@.Savmu25503.75533aN 255311 undemuM thuifNe Wilting
does No Carmody how a moans Nat it is my responsibility to nosey IW we ant of e
enuwhic a mel prior to Issuance of aCaere'sof m �. Signature of Applicant Date
watm or aathariwd agem Dam
All roof coverings to be Class"B"or better