08020191CITY OF CUPERTINO
Ȣtea oe A9,uP'"' , M"w
BUILDING DIVISION PERMIT
NkUTATIQu
„kCORA,nATaR
BUIL I ADDRESS
�l r'ES
PERMITNO. -
75 ROLLINGDELL DR
TBD.- TO BE DETERMINED
08020191
OWNER'S NAME:
PERMIT ISSUE DATE
PINNACLE
04/03/2008 "
PHONE:
SANITARY NO. CONTROL NO.
CirmicTmNaimaR:
BUILDING PERMIT INFO
FLAG POLE. ANC PD FOR BUS
BLDG EO PLUMB
O
LICENSED CONTRACTORS DECLARATION
Job Description
I botchy affirm Nat 1 am licensed under provisions of Chapter 9 (commencing
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with Section 7(110) of Division 3 ofthe SuunwaM Profudem. Code, and my license is
in full reme and affect.-3t
Licenm w Lk. a
.
Dau ��—Cmmrsma(
ARCHI'TECT'S DECLARATION
1 undertunJ my plans Nall be used as public records
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Licensed Professtanal
OWNER-BUILDER DECLARATION
I hereby a?tm that I am commit from the Commences License Law for the
following moon. (Section 70313, Business and Rafewans Code: Any city or County
which urinous a wantm continues, ally. imp.. demolish, Or repur any structure
prior to its issuance, atm requires the applicant for uch Permit o Ole a signed statement
that he is licensed pursuant tithe provisions of to Contractor's censo law(Chapmr 9
Sq. Ft. Floor Area
Valuation
(commencing with Season 7000) of Division 3 of d Business and Profeuians Cade) or
that ha is exempt themfmm and the basis for tion Melted exemption. My violation of
APN Number
Occupancy Type
SeNan 70313 by any applicant far a permit mbjwu the applicant of a civil penalty of
on, mom than fins hundred dollars (5500).
❑ 1, uawneroftind property, armyeroployeas with wage uti¢ir sok wmpcwtion.
e
Required Inspections
will do lha wet_ and thesuuenure isnminundedarenerad forum (Sec. 7044, Business
and Proresuons Cade: The Comnndoes Lkeme Law does not apply m an Owner of
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Property who brei Ida er ire pmvu thereon. and who does ouch wort himself or througb his
own cmployeu, provided Nal such Improvemmu art not inuMed oroRered forule. IL
however. the building Or improveromt is mid within ow year of compledw. the owwn
builder will have the burden of proving that he did rot build a improve far pufpom of
ask.).
❑ 1, as owner of the pmpeny. w exclusively conducting with IlemuW ca n rmun to
cmutmes the From (Sec. 7044. Business and Profession Cade) The Conmemrs U.
cuum law does not apply m an Owner Of property who builds or improves thereon, and
who contracts for such projects with a contrwtor u) licensed pursuant m dad Contractors
Lice. Law.
❑ Iamaemptundes See .BRPCfar thisfesson
Owner Data
WORKER'S COMPENSATION DECLARATION
1 hareby affirm under penalty of perjury, rete of the following declarations:
1 have utas will mmaln • Certificate of Cammat in self-date. far Wmtera Co rfam.
Find. u provided for by Section 3700 Of the Labor Cade. far am performance of the
as for which this permit is wood.
❑ 1 have and will maintain Workmes Compensation Insurance, as rryuiud by Section
3700ofthelaba CN.for Neperformanceoflu forwhichthi permitisiumd.
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My Workers Compensation Imannca carrier and Policy number am-: �'1LT�f
a
Canner. S ay 1404{ Policy No.: �-1
CERTIFICATE OF EXEMFITON FROM WORKERS'
COMPENSATION INSURANCE
(This secdon wed not bueompleved )the permit Is faaw hundred dallats ($100)
er less)
I cantly that in the performance W the work for which this permd is issued, l shall not
employ any parson in my mm erso as be became subject u the Workeri Compew0an
laws of Calirman . Dau
Applicant
NOTICE TO APPLICANT: IL after making this Certificate of Esemption. you should
become subject in the Workers Compensation provisions Or the Labor Cada, YOU must
foMwith comply with such provisions of Nis permit &hall be deemed ¢voted.
CONSTRUCTION LENDING AGENCY
1 heathy AMM that them is a contsuuctinn lending agency for the peafunnance of
Ne work for which thus Permit Is issued (Sec 3097, Civ. C.)
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Lenders Name
Lenders Address
1 certify that I have tend thli applicadw and sum that the above information is
corset 1 agree m comply with all city and county oWlnmcu and sum Ian moon{ to
Wilding construction, and hereby wthOriu Mfoosenuuas of thus city Or enter upon f
above-memom.M property for inspection purposes
(We) agree to save, indemnify and kwp hermkss 0te City of Cupertino against
.
j Ilmilitiu,Judgments. casts and expects which may In my way seem against mid City
1 in conxquncc of the grandng Of this permit
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT
Issued by: Date -/
sou_R,�flTec ��fs. 0-7
.
1�
Re-roofs
Type of Roof
Signature of ApplicanVCOnuwmr Dau
HAZARDOUS MATERIALS DISCLOSURE
Will the a fretum building tar handle husWous material
Use Cupertino Ca e. Chapter
as defined by tion Cupertino Municipal Cade, Chapter 9.11, and the Health and Safely
Cade. Second 25532(a)7
❑ Yu N
All roofs shall be inspected prior to any roofing material being installed.
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If a roof is installed without first obtaining an inspection, I agree to remove
Will the applicam or filum building occupant use equipment or devices which
It haurdnns at contaminants as deeued by the Bay Am Air Quality Management
all new materials for inspection.
vin?
❑Yca Q(Nu
I have roti the hasaNmu materia) requirements under Chapter 6.95 or the Califor•
nus Health&Sal, Cod,Sd.i 50S,25533and25534.1tutderwandthatifdv:building
Jas wtc M a `� a mspof&CetYbwd aceu�J
ro ren m[trr stmt ar,cetdraamar m
Signature of Applicant Date
All roof coverings to be Class'W' or better
owwrarm —�
onued.wnt Dots