06010077 CITY OF CUPERTINO '' "" ''* .' '
BUILDING DIVISION PERMIT ,CONTRAG�TOR INFORMATIONY".�.
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BUILDING ADDRESS: PACIFIC COMMUNICATIONS PERMIT NO,06010077
10400 RIDGE VIEW CT
O NER'S NAME: PERMITLSSUEDATE
GROSVENOR INTERNATIONAL LT 285 SOBRANTE WAY UNIT F 01/26/2006
I'MME SANITARY NO. CONTROL NO.
(408) 830-9550
ARCHITECT/ENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
u0o LICENSED CONTRACTOR'S DECLARATION' O O O
nuF 1MckyeffrmWt1amlicensed under pmvalofClopicr9(commencing Job Description
e< withS tion7")of Division3ofthc Busio dP fe ons Code.mdmylicenmi.s
-'cm infull fume and effect. REVISION--BASE LOCATION,
�� `i"" coay� "ea 1�2EINFORCE W/ (2) 4X6
to Date / Gonvaem(
F� —CTS DECLARATION NO NEW PERMIT ISSUED ORIG.
¢y+ IundcnundmyplansshallbeuseduPublic records / #05110143
>00 C
Licensed Pmfcseinnal
Bad I am exempt fr DECLARATION
<E I hereby aRm Nal 1 em exempt from tW Contractor's License Lew for the
pO which
mason.permit
riD LABusiness and proimprove.
demob Co de:my city or county
K$ which requires a permit m cnmwcL elms impmvc.demolish,or repair any swcmm
'lzi prior m its iuuame,also requires the applicant for such permit in Ole a signed smmment
< Nat he isliecvedpursuant toMepmvisiomofthe Commerce's Li"nmLaw(Chapter 9 Sq.Ft. Floor Area Valuation
y�$ (commencing with Section 7")of Division 3 of the Business and Pso(miom Codi)or $0
{l — Nat be u exempt therefrom std the baso for de,alleged exemption.Any violation of Y
Section 7031.3 by any appilemt for a permit subjects the applicant to a civil penalty of APN Number Occupancy Type
fiw
not more thanhundred&.Ilan($5(10} P Y YP
1,mmnuofthepmpmn ormycmploymwiNwa uNe4soleeommmad.n,
will do the work end the swcw¢is not intended oroRersd fonale(Sec.7066,Business
and Prof.Wom Calc:The Contractors Litten Law does nm apply in an mvxr of Required Inspections
Property who builds or improves Nerrnn.and who d as s uch work himsel f or through his
own employees,provided Nat such improvements art not intended mo0ered for sale.It.
however Ne Wil&in6 or improvemem is sold within one year.f.ompl.tion,the"wwr�
builder will have the burden of proving that he did not Wild or improve for purpose of
aets.l.
0 1.as owner of the prolsi am excluakely contracting with licensed ro ormums m
Construct the pmjen(Sec.7614,Business and Professions Cade:)The Contractors Li.
cense Taw don not apply m in owner of property who Wilds or improm thereon.and
who Contracts for such projects with a contraction(s)licensed pursuant in the Convenors
License Law.
❑I am uempt under See .B k P C for this rtas.it
Date
WORKER'S COMPENSATION DECLARATION
1 hereby a(Bm under penalty of perjury one of do following dech rations:
❑I have and will maintain a Certi com of Comm toself-insure for Workers Compcm
,titian.u provide&for by Section 3700 of the LJWf Code,far the performanceof&m
work for which this permit is issued.
❑1 have and will maintain Worker's Compi ration Insurance,as required by Section
3700 of dm LaWrCode,for the performan"of the work for which Nis permit is issued.
MEy,W�or/Itt' Cpot^p■�mu.n lnsu cearicr and Policy number art: ,
Cart... yr•wall Policy No,Z001
CERTIRCATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(This maim need rent becmnplemd if tic permit u fortune hundred dolian($IW)
ea.)
I«oily that in the performance of the work for which this permit is issued,1 shall not
employ any person in any manner an as us become subject to the WorknS'Compemuon
Law,of Califnmia Dam
Applicant
NOTICE TO APPLICANT:If.after making this Cenificam of Exemption,you should
become subject m the Workers Compensation previsions of the Labor Cade,you most
.J z forthwith Comply with such provisions or this permit shill be dceme&reroked.
z h CONSTRUCTION LENDING AGENCY
�-. I hereby Affirm that then is a communion lending agcney For the performance of
C'
the,wurh for which this permit Is issued(Sec.3097,Civ.C.)
QLenders Name
D z Lender's Add.
U Q 1 certify Nn I have reed this application and stem this the&hove information is
U. e m F comem I agrecomply with all city and county enumerates and sum laws mating to
OU Wilding construction,and hereby authome rePrtsemaiiWS of this city to enter upon the
r4 ahovetcs.judnedpmpent for impccti.n purymea
(We)agree to save,indemnify and keep harmless the City of Cupertino against
tabiLrrA incoiommumc,ofEmgrowing expeueswhich may in any way accmc agaimtsaid City
U z APLIC# T of EmgrowingSNis permit.
APPLIC UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT Issued by: Dale
SOURf R tiULATI 5
Re-roofs
begirmuse of ApplicanvCoommor Do
HAZARDOUS MATERIALS DISCLOSURE Type Of Roof
Will the applicant s future Wilding occupant store or handle heurdous material
as dcOned by the Cupertino Municipal Code.Chapter 9.11,and the Health and Safety
hoc. Ye25332(6)7
0s futureu`' All roofs shall be inspected prior to any roofing material being installed.
Ye )(No
Will the applicant or future building occupant uec equipment or devices which If a roof is installed without first obtaining an inspection,I agree to remove
emit Wvardnus air conteminan u dcOncd by the Bay Area Air Quality Management
District? all new materials for inspection.
❑Yu o
Ihave aNmrsrwcrials requirements under Chapmr6.95of&mCalifor-
niaHcalNhS y ,Seed..25505.25533.d25534.1.nW uandthvif&m Wilding
docs Ely w a amthat itg' y m pormed.ty m nodfY Ore oceupm'of the
mqu' m ewn� m. beme dovfoBsuan .eat aP " O Signature of Applicant Date
o n. naagent D,m All roof coverings to be Class "B"or better