00070138 CITY OF CUPERTINO
BUILDINC DIVISION PERMIT CONTRACTOR INFORMATION:
,IU I LDING ADDRESS: PERMIT NO.'
oWm:HSN�m6.655 SANTA LUCIA RD TOMARK COMPANY AI'PLICAI'0666'Y15i138
IONF.: SANII'ARl'INOOIL110IO CON'I'ROI,NO.
SWAMI, SAN .TAY 1081 SUFFOLK WAY 07/24/2000
O¢iARCIII'ITCrIF.NGINGER: BUILDING PERMI'1 INFO
° (650) 960-4044 HLDG ELECT PLUMB MECH
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m v I.nhad;U CONTRACTOR'S DECLARATION
$ _0 1,i 7( auhlmm mat I aril of III,
node poldiClubc of Chalner v(.nmmenethg Job Description
is I.full iooa,an cloccl i,cion lot the llndnetrmW Prulcvxioun Cndu,unJany license.
1jecro 11 luno and elf SO�LLq
s-6 Liceme Clnsv_,� cm e_ Qv 4
't a H U:ne S DIC rnr
° n11GmT1'etoe DI:CLnRAnoN TEMPORARY POWER
t= 4 1 understand my plans shall R nscJ m public rwnNc
y C p p Li.tood Prnfcoinnol
(IWNER-BUILDHR DECLARATION
1 hereby affirm,bar I mor cnpu fin,the Courmtnr's License Law for IM1e
L'K- following reas�nsseron 9131.5�Bmi,ms,and l•mfnsions CWc:Any ciryor county
d C
which reclaims aPs ait to carivract,atter.impouc,dcurelikh,or repairany structure
m— P,I in it,- Ina I 'th pica t bo'unell c nl 1 Ir, :lll utcmcnt
da
that he is licensed pt—marit to the pol of theContractor,LiLaw(Chapter9 Sq. Ft. Floor Area Valuation
(commencing with Section 70(k)of Division 3 of the Business and Profmarns Code)
or that he Is cwiapt therefrom and the basis for the alleged exemption.Any violation
or 17031.1 by any tppllemn fIl a pam,h lobjeel'etc app"L....m a civil pcnnhy
nrnolmnrethan live hundred dollars x5N)r APN Number OccupancyaType
01,as owner of the prnpeny.or my employer with wages as their sole emnpenunion. 11
will In the work,tine the,lol is not immnded or o0emd for are(Sec.7094,
Business end Pmfcs,ions Code:The Cnmmc,ar.Ursula Llan does mm apply to mrquired Inspections
owner of pso,ery who haild,or improves thereon,and who does such work himself 3421.7007. 0
,, rmgh bis own c.npluya'u..provided Char such intpoovorc n,are not intended a,
offered fur vele.It.1 1111 building nr Intpmvanen is old within one year or -
,mal,he owner-Nuildarwill have the burden W proving thio he did not huild or
hnprovemrpmpnxcef,ale.). 304 — ROUGH ELECTRICAL
01.m11w net of the wl;,,ly.morsclus,valy.nm,aemg with H"ll-ld Iom-1w;os to 501 — FINAL ELECTRICAL ENERGY
rnstox ct the project axe.7(U4.Business and Profen+Mm CWc:)'@e Contractor's 505 — FINAL ELECTRICAL
Lic<nLaw docs no,apply to an owne,of plops.}who build,or improveson
there .
1mJ tuba enmmels 1111 such Ill wish u cunlexul )Ii,vowd puounal to the -
Cn mlo is I.icanuc Lltw.
01 am exempt under Sea .B&P C for this reason
Unntur - Ilure -
WOHKIiIt'S COMPCNSATION DECIARAI'ION
I herehy mfrnn under penalty of Nary one of the following Jeclamtion,: .
❑ 1 have and will reduain a CeriFc:nu or Concent 111 mlf-hotme for W..ker'n
Compensation, as provided for by Section 3700 of the Labor Cole, for IM1e
performance of the work for which this pemmi,Iv is,aed.
01 hm'e mad will maimmia Worker's Colopenwtlou Insurance,as required by Section
37W of the Labor Code.for the performance of the work for which this permit is
mad My WorkeV+ClunNmarion Insurance carrier and Policy number are:
Cantor:_I'ulicy No.:
CERTTII9CAT ION OI,EXENIETION FROM WORKERS,
COMPENSATION INSURANCE
(This section need not be completed if the permit Ls for one hundred dollars
(SKO)II less)
IQ&Akin,
In rhe IsI ....n mo of the wad fur which this permit is i,csued, -
shall nnl r ms m hccunm subject to rM1e wurkeri
_Ihi+Ccnilicnle of Excn.ption,you shaulA -
loss,nae,ubjecttotire Ill,Cnmpcnsmian povision.,of the Labor Code.roti must
Q Q fonhwit comply with such unw inns or this permit shall Ne deemcal revoked.
HiCONS T RUCTION LENDING AG17NCY
> I hereby mr0nm that there is a constrvcrion lending agency for the I,crinrmence
flit,work for which this permit is issued(Sec.307.Co.C.)
L (� Lenders Name
Z la1cr',Addrv,,
U C I venify,hm l have road,hl,aInd emim;mad state Nal the als ve information is
W. F. cerrect.I agree 1n comply with all city and county and ores and.care laws relating
Q (� to hnllding, werulion,and hcmby art, mon", Pct-cnunirc.v of 1111,ei ty to curt,'upon ,
,he aMwomemloned pull for impaction pmpmcc.
(We)agree nosave,indemnify and keep harmless the City of Cuperino ti l
In liabilities.judgmems.curls and mpen.ws It may in any way acme againw said
(� .Z_ City in conse4ucnce of the granting m Nie penrlt.
ll APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON POINT Issued y: Date
SOURCE REGULATIONS.
sigm nrornrpu.anllcnmme,or D1.In Re-root.
HA9�+HDOUS AIATEHINS DISCLUSUHIi
Will the applicant m future building occupant sate or handle hazvdou,lna,e nal Type of o
derma by the Cupenino Mrmieip:d Cade,Chapel 9.12.mod,he Health mod Safety
Code,Section 25532(a)?
O Ye, 0No All roofs shall be inspected prior to any rooling material being installed.
Will the olvdcam or mire bu0dang occupant las,equipment or devices which If a roof is.installed without first obtaining an inspection, I agree to remove
mil l tumor"l...a,nl....nanny m Jefncd by 0th Bay Arca At,Quality M:magrmcmt
)is'He,'? all new materials for inspection. Applicant understands and will comply with
OYes [2 No all non-point source regulations.
I have read Iha ha,md lnnteials v,mo auvaas under Chap,er 6.95 o1'the
California Heahh&Safety Code.Sections 25505.'-5533 and 25534.1 mulemand that
ifthehuilding Jan me renrly h:wamtenan6 thmil i,my responnibilitymnmify the
,....peat of eta len,w.1 aanve It a Cenmemr of
O,va ancy' Signature of Applicant Date
own—ern ammo; -n ��>:n� All roof coverings to be Class "B" or better