05080163 CITY OF CUPERTINO �v �asv:r«a�,�ai�w " > +7��y�� h'
BUILDING DIVISION PERMIT �"VQL`I%l'l� GTOR NFORMA00 ,
BUILDINGADDRESS: CUPERTINO CONSTRUCTION IN PERMITNO.05080163
10578 SAN LEAND O AVE
R'S NAME: PERMIT LSSUE
E
AMILIA INVESTMENT L. P. 10079 SAICH WAY DATE 1 2005
HONE: - SANITARY NO. CONTROL NO.
(408) 253-9000
ARCHITECTIEhIGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
0 0 0
o LICENSED CONTRACTOR'S DECLARATION lob Description
1 heroby.firm that I sm limned under provisions of Chapter 9(commencing
IN Section]0110)of Division 3 of the Busirteaand Professions Code,and my license is
aj'❑1ry i�fullforoeandeae REVISION--INSTALL SEWER PUMPER
Lug Liccnss Clans sae.«ractor NO NEW PERMIT ISSUED/ORIG. #05020181
3 Date TS DELL
ARCHITECTS used
DECLARATION
I understand my plans shell he uud u public records
aG Lkenud Professional
OWNER-BUILDERoexemptDECLARATION
0I I hereby.(sec that 11. exempt from the C Professions
o :Any c Law for the
I O fallowing noon.(Sautes]0313,Business and Professions Code:Any city ai county
$V.r which its issuance,
a permit a construct,alter,improve,demolish Permit t ri e 4 sig any Emmen
_Z SQ tprior hat k i u lssnsed pus requires theapplicant forsuch Permit m f...Law
(Cha mem
< dW hCµcingwii SeNan1100M of Division
a(dK CanusinctfLl0..0Yssno CNde)or Sq.Ft.Floor Area Valuation (]
F
that
s
(commencing Section 70nd of D asisfr the
theeged esa and cart.Any vi Crude)or
��.. Wt he 4 exempt therefrom and the baso for the alkgcd eumptim.Any violation of
Section 7031.5 by any applicant for a perms wbjau the applicant An a civil penalty of APN Number Occupancy Type
net mem than Run hundred dollars(350D). 35705046 . 0 0
I,u owner of the propmy,or my employees with wages as their sole compensation,
will do the work.and the structure brat momeled oroQcrcd for ask(So.70/6.BusinessRaired Inspections
and Professions Code:The Cmancefa License Law does not apply n e an manor of q p
propeny who builds or im proves thereon,cad who dues nuc h work himul f or through his
own employees,proviciod that such improvemcnuam notdnunded oranered for sale.It.
however.the building or Improvement is old within one year of completion.the owner•
builder will have the burden of paving that M did not build m Improve for purpose of S
sok.).
D 1,As owner of the property,am exclusively contracting with licensed antraa0n In
construct the project(Sec.7046,Business and Professions Cade:)The Coommutes V. '7 Jj\
cense law duca not apply in an manes of propenY who builds or improves themon,and
who contracts fa ouch projects with a comnattor(s)licensed pursuant to the Conuunrs
License Law.
❑I am exempt under Sec. .B g•.P C for this rtaan
Dan
WORKERS COMPENSATION DECLARATION
1 herby AM=under penalty of perjury arc of the following declarations:
❑I haw acrd will maintain aceNncem 4comm.t n air.m..ro fa WorkeesCampcn-
salion,an provided for by Section 3700 of the labor Code.for Ne performance of the
work for which this permit is issued.
❑I have and will maintain Wekers Compensation Insurance,As required by Section
3]00 of the Labor Code,far the performance of the work forwhieh this permit is Wucd
My Wmkees Compensation Insunoa carrier and Policy number aro:
Cartier: Policy No.:
CERTIFICATE OF EKEMP ION FROM WORKERS'
COMPENSATION INSURANCE
(this motion nm i not be completed if%M permit Is forone hundred dollars(SIM)
mks.)
I cerdfy mat In to performance of the work for which this permit is Issued.l that not
employ any person in any manner an As in become subject to esu Workers'Compensation
Laws of California.Date
Applicant
NOTICE TO APPLICANT.IL after making this CcdiRate of Exemption,you should
become subject in the Workers Compensation provisions of roc litter Cade,you must
wJ Q forthwith comply with such previsions or this permit shall M deemed revoked, '
'ZCONSTRUC ION LENDING AGENCY
`
t, I hereby affirm that then is conmrucdnn lending agency far the performance of
C' > the.,it for which this pemtft b issued(Sce.9197,Civ.C.)
Q lenders Name
7 z Lenders Address
V 0 1 anify Na I haw read this applicNon and sex a that the also.information b
correct.I agree to comply with all city and county ordinances and sure laws relating to
0 building construction•and hereby authotim representatives of this city in enter upon the
fll maw mentioned Property for Inspection pupaaa
(We)agree to saw,indemnify and kap harmless the City of Cupertino against
y liabilities,judgments,coma and expenses which may in my way aceme against aid City
U Z In consequence of the granting of this permit.
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT Issued by:9 Date
SOURCE REGULATIONS.
Re-roofs
Signature of ApplkanUCoO Date
HAZARDOUS MATERIALS DISCLOSURE Type of Roof
Will tite a Cupertino
W fou ni Wildingh,Chat 49.1 orand t e Heardoa material
WA dcfimd by the Cupertino MuniciMl Code.CMpter 9.13,and tits Health and Safety '
Section 35533(4) All roofs shall be inspected prior to any roofing material being installed.
❑Yes ❑No
Will the applicant or future building occupant us:cquipment or devises which If a roof is installed without first obtaining an inspection,I agree to remove
emit havardnus air contaminants As defined by the Bay Area Air Quality Management all new materials for inspection.
District?
❑Yes ❑Nu
I how rand the huardtes materials roquirorecnts undcrChapur6.95 ofthe Califon
ale Health@ Safety Cade,Sections 35505.35533 and 25534.1 utnkrststM that if the building
does not cuncn ly haw a tenant.Nu it is my nspnnslNlity in mury the a espant of the
requirements which must be met prior a fasuame oft Ccrtificem of Occupancy. Signature of Applicant Date
Owner or authorived agent Date All roof coverings to be Class"B"or better