04110152 CITY OF CUPERTINO g��. �r a�w3`*«x.
BUILDING DIVISION ... PE
RNIIT
BOILDRIGADDRPSS: LARRABEE & ASSOCIATES- INC- PERMIT NO 4110152-. -
7440 ROLLINGDELL D
9R'S NAME: PERMIT ISSUE DATE
, 'TOM CHU 36 RAILWAY AVE
PHONE: .. _ .._ SAN IARYNO_ .., _CONTROLNO. ..
(408) 364-9000
ARCHITEC(ENGINEER: BUILDING PERmrr INFO -
BLDG ELECT PLUMB MECH
0 0 0 0
LICENSED CONTRACTOR'S DECLARATION
t I ppecrtby affirm Wham IieetvN miner provisions of Clupo:r 9(rommeneing Job DO$Cr1pUOn -
with'Seyu"dt]011tp of Division3oflhe Bun Profesioa Code,and mylicense is
mmufareeanaerr L VOLUNT. FOUNDATION UPGARGE
tb= License Cl B R . : -...._ -
y7 ARCNf1EC1'S DECrXRATIqN
-r 1 undcuunJ my plans shall be usedrJs
Laminated Professional /`4 /Q L
OWNEns exempt
DECLARATION
0 0 I herthy affirm o n 1 am eumpl from the Cortins Co :Any c Law for the
2 O following mama Permit
1 ]1131.5,comment,after,and Profeedun.Code:Any tiny or county �
• ��n` which iU inU a permit sea i=ffiealma improv,demolish,rl repair any structuremwment .. "_ -... _
,rZ�, pHW mIb ISSYNc0.ilm mgWll'S IAC apphemlfnl6n[A pCIr11111U Lilt itlgned ilammenl _ _ ._..
SS ts Na he it licertseJ purmam mthe Provision of lAc ContrumrW¢ae Vw(CMpmr9 _ Sq.Ft. Floor Area _ Valuation
K $ 0.,W .exawithsufiournand of Division3 alleged
as.pit..
Cade)ser
Nn io la campy therefrom and de,aper far de,alleged emmant to Any it penalty
of
notus7031.5
m rn any
narta applicant for
(ism) o subjects Ne applicant m a civil pemby of a Occupancy Type �I
❑I.a Desna of Ju pmpeny.m my emplayeei with wqu u Noir mle compenudon,
and
Profession,
roena :The Committees
Lt. ar Law
does at apply a I...I,of ,Required-Inspections
• and Pm(eslobm Code:The Comm�ors License Law moo not apply m an owner is - - Q
property enywhobulldtorimproves th improvements
andwho ane sot in work himmlforthrough his
however.the skiing orided prInch vemimprowmantaertne earofcomplatended credtheWalr-
• however,theavet the burden
of provntiamld withinoneWeld of[ prove foron,the owner- ... •-, __ _
builder will have Ne buracn of Proving that he did not build or Improve for purpose of '•' --•�- '�-'-`--•'•"-_"- ' '-" - �--'-""" •,
tile.).
1,a mune,of de,progeny,am"elusively contracting with licensed con=(.,to ,
construct Ne project(Sec,]Dam,Baines and Profusions Code:)The Continuum's Li. -
«tie law does not apply to an owner of properly who builds or improv thereon.and
who contracts for such projects with a canummr(t)licensed pursuant to that Contractors _
License Law.
❑1 am exempt under Sac. ,B 8,P C for this mown
e, Dale
WORKER'S COMPENSATION DECLARATION -
1 Aereby afame under penalty of perjury one of dee following deeluadnn.:
❑1 haw and will maintain a Cerdficas,of Consent in self-insure for Workers Compere
sation,as provided for by Section 3700 of dee Labor Code.for the performance of the
work for which this permit is intim.
❑1 have and will maintain Workers Compensation Insurance.as required by Secdon -
3] of the laborCode,(or the Performance of the work for which this permit is mined.
orkers Com penmdan Insurance cartier and Policy number art:
CaniFD Policy No.: 7 4V
i/ CERTIFICATE OF EXEMPTION FRO WpRK R: S' _
COMPENSATION INSURXNCE
(Tots melba reed not he complclW If the permit ta Intone hundred dollars($100)
or less)
1 certify Nat in the performance of[be work for which this Permit is iuted,l shall not
employ anypermn in any ma ma r an as in become subject to the Worker!Compeuauon -
laws of California.Dave
Applicant'
NOTICE TO APPLICANT:If,after making this Certificate of Exemption,you should
become subject m the Worker's Campenmuon provision.of the labor Code,you most
.,O forthwith comply with sten provisions or this permit shall M d
deemed revoke
zt••'
CONSTRUCTION LENDING AGENCY
I hemhy.farm they thew ire coamclon lending gency Tor the performance of
0.i 7 the work for which this permit is issued(See.3091,Civ.C.)
fxl Q Lenders Name
7.. Lender's Address
V 0 1 c,,dfy they 1 him mad this application and main Nn the above Information u
ft' F COMIL I agru in comply with all city and county onfinances and sum laws mlning to
t7U building construction,and hereby mtAorim representatives a(this city to enter upon the
W shove-mentioned property for inspection purposes.
(We)agree m saw,indemnify and keep hermles the City of Cuperdno against
L.I VI liabilities.fudgmenm,casts and expeau which may in my way accrue against mid City
O'j, in conuquerme of the granting of this permit.
" APPLICANT.UNDERST AN OMPLY WITH ALL NON-POINT Issued by: - ' Dale
SOURC EGU S. a
�23�dy Re-roofs
Slgnnu afAppIi.lA orunmmr ��
HAZARDOUS MATERIALS DIsc,,%I —
E Type of Roof
Will the applicant or future building occupant atom or handle hanardous mamrial
deRoad by On Cupertino Municipal Code.Chapter 9.12.and the Hcalth and Safety
.Secdun us3Zi'I1 -
❑Yes ON. All roofs shall be inspected prior to any roofing material being installed.
Will the applicant or Nome building ouuupon[esu cquipmuy or devices which If a roof is installed without first obtaining an inspection,I agree to remove
emit hnurdous air contaminants a defined by Inc Bay Area Air Quality Management all new materials for inspection.
District?
❑Yes ❑Nu
I have mad the numerous malsrialsmquimmen s under Chapier6.95 of the Califno
I thkSafcly Code, 25s05.25533and25534.1undersund Nuifih building
d t currently lona. t it'is my w mihilily m notify tie oauPanl of the
req. In 9 IamenceacomRcamar spa . Signature of Applicant Date
k 2B 9f
owner ur rot arbcJ agent Q,m All roof coverings to be Class"B"or better