06110130 CITY OF CUPERTINO 'j,
BUILDING DIVISION PERMIT aCONTRACTORINFQRMATION -
$ s.
BUILDING ADDRESS: PERMIT NO.
OWNER'S NAME: 1,,"
APPLE 170 KNO14LES DRIVE STE 120 12/19/2006
SANITARY NO. CONTROL NO.
WE (408) 379-5500
ARCHITECTPENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
00 LICENSED CONTRACTOR'S DECLARATION
Job Description
ffi
1 hereby affirm Nal e
al l me Recover!under provisions of Chamber 9(commencing p
w wiass emion7OW)aCID i'ion3oIda eBusinenxtlPrafcuiunsCwe,an myhanmia INSTALL NEW 1HR TUNNEL CORRIDOR CEILING' LID,
in full forte and efftts��?
2 i6q7- �/LicenmC L'w.g l !V! 1 LIGHTS AND VENITLATION
r w Dam Conuxwr
J
ARCHITECT'S DECIAR f
i w< 1 unlicensed my plans shall he used as public sa bdi
i U
'C G Licensed Professional
OWNER-BUILDER DECLARATION
)C 0 1 W rthy a1Bnn on I aL.uempe from the Csafter o License Law for the
p o following massa permit
a]1131.$Business and Pro.marmi Cade:Any city or county
which requires n permit re caaec,de, alter,impmsu demi W, file
repair any smemm
prior to i6 issuance.also lrQai Ra pMaiions oI forthe NrhPermit wet Laedstl@mrnl
< that he is licensed Presume to Nc provisions of Nc Cantacwr's Lignac Law(Chapter9 Sq.Ft.Floor Area Valuation
i1- (commcncingwiLh ecdon70DO)aOivuion3ofl BusinsaandharmiamCale)ar $25000
$ that he u exempt Nerefsom and Ile bus for de,alleged exemption.Any violation of
Section 7031.5 by my applicant far a permit subjects the applicant m a civil Penalty ofNumber Occupancy
not more than Ow huadsed dollars(3500h 316 0 6 0 2 9 . pane y Type
❑1,u owner of the Property,ar my employees with wages as their sale campcnsedo.,
will do the work and the swmure is not intended or offered for (Sec.70,14,Business
and Professions;Code:The Contractors License Law does out apply in an owner of Required Inspections
property who Wildsorimverve&demeon,and whodeessuch works hamelfor through his -
own employees,provided Not such impravemenu are not intended oroffered formula.If.
however,Ne building or impmvsment is sold within one year ofcompladoo,due owner,
builder will have de,harden of proving that W did not Mild or improve for pappose of
role.).
❑1,as.wncr of the property am exluvvcly...testing with licesed conuxurs to
corer m t the project(Sec.70x4.Basin and Pro(ezunm Code:)The Contractors U. -
cause Law does not apply w an owner of property who Wilds or improves thereon,and
Who contacts for such projects with a commoter(s)licensed pursuam to the Courtrai -
Lice.Law.
❑1 am exempt under Sec ,B&P C for Nis an
Owner Data
WORKERS COMPENSATION DECLARATION
1 hereby sRrn under penalty of perjury one of the failm,ing dxlarauons:
hart and will maintain aCeruGcate of Consent to self-insure forWorkers Compen-
atian.u provided for by Secure 3700 of de,Labor Cade,for the performance of the
work for which this permit is issued.
❑1 have and will maintain Workers Compensation Insurance,as required by section
37th of the labor Code,for are performance of Ne work for which Nu permit is issued
My Workers Compeuadou Wurana artier aMPolicy number are:
Gama': CLo bl;� -YWCt—OV.116'—Na: b3 -a I _
ERIIFlCATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(Thu If.need nc1 W completed if the permit is finene rundwd dollars(5100)
or less)
1 comfy Net in the Performance of the work Be which this permit is iuued,1 shall not
employ any person in any mannerw as m become subject to de,Worke 'Compensation
Laws of California.Date
Applicant
NOTICE TO APPLICANT:If,after making this Ccmiricate of Exemption.You should
thecae,subject an the Wofk,r's Compensation provisions of the labor Code,you must
.JO forthwith comply wide men pmvisiau or this pe.it,h.11 he deemed mwked.
?C7 CONSTRUCTION LENDING AGENCY
rr•� Ibereb,.M.that Here is ae..,inn lendingagcmy,for the penrarmanauf
the work Bur which his Permit is issued(Sec.3W7,Civ.C.)
W�Q lenders Namc
=2 Lenders Address
U O 1 certify Nat 1 have teed Nis application and sow that dee above infonmaaun it
La. P^ cortex.I agree to comply with all city and county coinsurers and sum laws misting w
OU building conmuclian,and herehy aulhori rempresenuniws of this city to enter upon the
4 .ahovc-mcmbncd ne.c ac for a penes pugwmx.
(We)agree Io arc,Indemnify and keep hmmless de,Cay of Cupertino agsimt
Uz unpeideguncaru.costsand of[his
may in anyway attrvc against mid City
U,z in ncc of Nc germing of This permit.
PLIC UNDERSTANDS II.L COMPLY WITN ALL NON-POINT Issued by: Date — (9_0e'
OURCER l.ATIONS. X// 'c'-�P gib
Sizemore of ApplianUCon—un '7th Dan, Re-roofs
HAZARDOUS MATERIALS DISCLOSURE Type Of Roof
Will the appliant or future building occupansm ea or handle hnmdous material
as def ra d by the Cupertino Municipal Cade.Chapter 9.12.and IW Ha1N and Wet,
Code,Section zss33(a37 All roofs shall be inspected prior to any roofing material being installed.
Yon Nu
Will thea fncent.r al re holding occupant am If a roof is installed without first obtainingan inspection, I agree to remove
PP B P e.Air a to which Pe g
I haxaNnus air conmminanu u dcfirwd by dm Bay vera Air Quality Management all new materials for inspection.
iYlrlet7
QYa KN.
I have mw the haxallous mawrialsrequirements underCWp orh.95 of the Califor-
nu SafclyCwc,Section 35505.25533 mal 25534.1 m rcaused thatiftW Wilding
,_I
of c rely ha.e a anon✓`,IA' u my res nsihilily o notify the..pare.f Nc
mgimmcn iahmaYlbc ' ai oars .,a I, —Y. Signature of Applicant Date
�J kLlrYl0b
Owner of authan,ed agcel Date All roof coverings to be Class"B"or better