00070097 I
CITY OF CUPERTINO
•BUILDtlx:DIVISION PERIMIT CONTRACTOR INFORMATION:
BUILDING AIj)U'1S15 SAICH WY XL CONSTRUCTION I'ISRMIH No'00070097
OWNhR's Nr�t�SIA 1500 BERGER DR AppI.ICATIO0jB�lAi6/`000
°
(408) 271-2425 SANT IARY NVOJ/ 1 / CONTROL NO.
C e 0 ARCHITEC(ENGINEER: BUILDING PEItMI'I INFO
❑❑ LfKs ELECT PLUMH MECIf
zuU I_ I� I_I I---1
�?O1 LlCENWILCON'1'1RAGIOR'S OLCLA1N'I'ION
w= Ihemybarammthat[amtlicensedunderpnwidon,ofChapter9Bmmmencing JobDescrip ' m
FNtp while.°ann7pMnonrvidmt3onnexrime%,.a .. .m n.eme,andmrha.nse SIGN
is in fill[force and effect.
z a Lmull Cl�a- �� Lica_ _
3 c° Mlle —/—[—'k Cmmacmr �71/bD_ �l
u_O \ L 1 fECT'g DEChARAII 'TJ r/�f/ /'a-
y I andcntu si ny,mns shall be asci us public accord,
Licensee[l'mfe%,ional
OWNER-BUILDER DECLARATION
I hemby.1 imt that I uin exctn,t from the Contone mrs Licen,c Wed for the !/
h Z� following reason.(Section 7131.5.Business and lsmfes%iwe Code:Anv city a pmnry
E O wIh,b -c,ap mitt unai,ill r, p F,h,o,mvy,mmam
3
prior in itsm lsonar the applicantf permit tofile a signed mcmareat
that be licensed flower to p n, nn Contractor's L W (Chapter9 Sq. Ft. Floor Area Va
motmnencmg with Section n 7W1)el Dlvrvion 3 ill the 13aslnr, and Ir...['.„roil,Code)
or that he is emmpl therefrom and the basis for the alleged exnnption.Any violation
of Section 7031.5 by any appbcant lir a pemlh subject%the applicant to a civil finally
of net more mato five hundred dollars 155pn Alali , �C'I�(34. 00 Occupancy Tyft
D1,asownerof hepmper,,orIt,enlpinyccwahwc,r uamen.o1.clumcn,:vion.
will Jo the work,and the Llaaum is not intended or offered lir sde(Sec.7314, + �p}}',[1�1��,y,�ffy1tr,'
xusines.and Podc,yonn Ctde:The Contmnor',License Low does mm apply 1.oo 1.01
— FOUIV UH 11141 VNpections
ndpmpcny Who builal,or Improv..thereon,and who Jo.c such work hinncll
or through his oxm employees.pmviJeJ that such improvements we net intended or 103 — UFE R
offeredm
for Laic.IL however,the building or inmrovcent is sold within one year of
iompletion,tire owrcnhudnerwill havc,hdtarmnnrprnvor,detIt,didmalharder 104 — REBAR
mprove for pwrwe of,aIc.)L
D1.as owner of property,ant exclusively coraraaing with liccowd co trachmlo - 7.05 — ANCHOR BOLTS
L°.sect he pore.,(See.7(w,Blume,orad prnfe..ion,Cade:)The Contmmur, 304 — ROUGH ELECTRICAL
icen.w Law doe,rel apply m an owael of po,puny xho build,nr im,uo—dmrom.
and who contracts lot such projects with a cnntmclm(s)hcenwd pursuant to ha 505 — FINAL ELECTRICAL
Commenr'%Licen.e Co..
D l am exempt Linder Sec. _ .n x 11 C lot mix re:l,on 514 — FINAL PUBLIC WORKS
U owner Date
WORKHR'S COMPENSATION DITCLARAI'ION .
1 hcrvby utlinu under penalty of perjury one of til.follow my dalunnion%:
I have and will maimma a Certificate of Contur
Consent to wif-inse for Worker',
o' Compovution, as provided fur by Scam, 371X1 of Ill. Labor Code, for the
man
perforce of the work fill which this permit is icsucd.
01 have and will neinmin Wmdcr'.Compemutinn la,tua cc,u,re4airvi by Section
37W of the Labor Cede,for the performance of the x.,k for xhi,h his pemtit is
_ wed,My Wnrker'a Cont,enxatinn Insurance nmric,and Policy ntmther am:
Carrier: �� PLO cy No.:
CICR'I IFICA'IION of E%EMI'MON FROM WORKERS'
COMPENSATION INSURANCE
(This%ection need not he completed if the,emit is lint one hundred doHms
(Sip))or less)
I certify that in the performance at the work lir which this permit i,issued.I
%hall not employ any peraom in any nenner on a,to become subject to the Worker:
Congensntion LawsurCobb I...in.Dam
ant
ICH TO APPLICANT:IL ximr making this CenlEcae of Exemption,you should
elb comply with
the Wolds Compematlonp.it hall hehe dellice
Conceal tnu.vt
Q Q rnnhwith comply with well pnwisians or this peamil shall be J.cmed rernkcd.
E' 7 CONSTRUCTION IATNDING AGENCY I hereby affirm that there is a cnmwction lending agency lir the performance
ol'tbe wad fur which this,,coni[Is isnned(See PR)7,Clv.C.)
g1. Q Wndass Name ..
5 z lender's Addm,,
1`.7 Q l certify that l have read this application and state that the atone information is
W correct.I'agme m comply with all city and eoumy o..lawrees and note laws timing
Q [) rebuilding consuueion,and herchy amhorim represeM,okes(11`1111%city to corer upon
r� Ise came-mentioned properly ter inspection furrows.
s Q,o en(WI)egnc.tosttvc,indemnify and keep hnrndess the City nr Cuperou against
Vi liabilities,judgmt,,.°vats and esperl",which may in any way neural, tgainst.slid
V z City In cunwquence of the granting of this permit. —7
APP .ANT UNDERSTANDS AND WILL COMIPLYWITH ALI,NON-POINT Issued by: Date
S RCE REGULATIONS.
mrcof ApphearwCom.1..r Ume Re-roots
as
HAZARDOUS MATERIALS DISCLOSURE
WJltneapphmmmluo,mddingCrcrmmstoreormndlehuaardousmarrial Type of Roof
asdefined ba
y the Cupemao Municipal Cede.Chapter 4,12,and the I[.oast and Satiety
Code.Se,lion
GYeL 25532mL El No
All roofs Shall be inspected prior to any roofing material being installed.
Will the applicant or future buildingocvnpnrt use equipment ordevmeswoven If a roof is installed without first obtaining an inspection, I agree to remove
I horrendous air enmanuments as defined by the Boy Arco Air Quality Managcmem
den all new materials for inspection. Applicant understands and will comply with
Dae, 0N all non-point Source regulations.
\ I have read the h to ar1m,mamriaB mloimmens wader Chapter 6.95 of the
t California Hatch SO Safety Cuda,Sectluvs 255115,25533 and 25534.I enderaund hat
-f-b,,
f the building does not atrremdy have a awma,that i1 is my respom.ihilily 10 notify the
H m:cupam of the re4niret11cry.`whi tnua be amt prior It,i>,amae of a Car itievte of
Coe °Lucy, (/—/gJP1Y/' Signature of Applicant Date
ror amnori.edag tet C Data All roof coverings to be Class "B"or better
OFFICE