08010138 CITY OF CUPERTINOa " .d ' s£'
BUILDING DIVISION PERNIIT �COPI'.� r, Rt-�I1 FOR`MA7.'IfJ1V
ox .f.„,�C ».r t'lu.4 .
MIT NO.
BGILp/1tiD�TTbUIREW00D WAY TBD - TO BE DETERMINED ,< PPA 08010138
I
jrNAyME:S PEItMR RS(IBDATE
ITRAM TON. 03/07/2008
PHONE: SANITARY NO. CONTROL NO.
ARCHITECTIENGINEER: - BUILDING PERMIT INFO
ADD 591SQ + 118 BLDG O ELECIr PLO O
Sao LICENSED CONTRACTORS DECLARATION Job Description
rdx F I haWt
ereby tm 1 am Reo
Readmit under Provisions of Chapter 9(commencing "^^-^'
< MthSection7gkl)of DlWtlon]of No Butlmuaed Profcetlum Coda,and mylicenSa is
r �, in full forte aha cRrst
�? I.icenu Clw lde.• .
0 Da¢ GOn DECLARATION As shall used
DECLARATION
1 underaunJ my plans Mall W used u public record,
gtad Liccwd Frafasional
5^ OWNER-BUILDER DECLARATION
4 i 53 1 hereby affirm Lau I am exempt from the Convector',LicenSa Law for din
C D o following mason.(Section Tin I.S.Business;and Professions Cale:Any city or county
C$ which requlto a permit to ennumet,alter,approve,demolish,m repair any swctum
;S Prior w its issuance.also rcquircs that applicant for inch permit to file a signed comment
BxID did tee licensed purwant to the provisions of the Commerce,U..Law(Chipm 9 Sq.Ft. Floor Area Valuation
F9 (commencing with Suwon IUD)of Division 3 of the Budd,and Freshman Code)or
and he is omnpt them0om and the buil for the alleged eammptien.Any violatma of
Section 7031.5 by my applicant for a permit subjects W applicant to a civil penalty of APN Number Occupancy Type
.at come than five humircd dollar($500).
❑I,u ownm of Die proper y,m my omployera with w{o as thebrsole eompensmion,
wiRdotM ae4.dthe,w ismilntendedmoRem dt.s (Sec.7044,Busines,
and Psofnsdons Cak:The CanuaMra Lk.Law dons Out appy m an awns of .. Required Inspections
pmpeny who builds or improves lhereon,and whodoanuch wotkhimiefor through his
awn employes provided Nat inch improvements vat not intended aroffercd foaale.IL
however,the Wilding or Improvement is sold within one year of compkdon.the owner,
milder will haw that humen of paving dist he did rot Atid or Improve for purpose of
Lu .l.
1.u caner W the Properam, exclusively..=Ing with licensed tau conumto
nsvuct the Project(See.7014.Businessand Profadons Cale:)The Contractor's Ll.
me. Law docs eat apply m an owner of proper who builds or impow themon.and,
who conuacta for such pojcma with a contauter(O Demand pursuant to the Canuactora
License Law.
❑lam uemp mount See .B&PCto,this
D� 37
WORK 'S COMPENSATION DECLARATION
1 hereby affirm under Faulty of perjury one of the following decalWren
❑1 haw and will maintain aCeniDomof Care ent to self-Insum for Wortees Compton.
sWon,u provided for by Section 3700 of the Labor Code,for the performance of the
wad for which this Permit is tuned.
1 haw and will maintain Worker's Ommpensuion I..,as required by Section
3700 ofdhc labor Cone.for the perfarmanco of the wink for whicb mus permit is imm t
My Wul are Campensmian Inunnm artier tad Policy number tie:
Carder. Policy No.:
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(This semi^need not be completed if the permit is faro.hundred doom($10(y)
or led.)
1 ceniy dist In the perfomunm of the work for which this Final,le utmd.l OWI not
employ any perms in my manrcr to u to�mc anbjeci to�he Worken'Compewuon
Lawn of Califamia.Date
NOTICbecome suh PUse WWr If,after Compensation
the Cesio m Exemption..y utmost
.,Obecome,comp to Ons Worker',Campmukhis provision,mai of the Labor rCade you mull
roMwith comply with such provitlans o Nu permit Nall bu domed rooked.
z� CONSTRUCTION LENDING AGENCY
(—d I hemhy aRrm that then is•consvuctinn lending agemy far the performance of -
ai > the work for which title permit is issued(Sm.3097,Civ.C.)
W Q Undoes Name
z Larders AddrtSa
()Q 1 cuufy Last 1 have rod Thi,application and mute thu the thew information u
comet 1 agree to comply with alt City and county omionms and sum laws miming to
CSV' Wilding construction,tad hereby mmorim mPresenuuvem of this city to cnmrupnn Ne
[id abom-mentioned property for inspection purposes,
(Y (We)ages to at indemnify and keep hadenku the City of Cupertino against
y ftabinda judgments.cru and expenses which may in my way amue sgtlnst Said City
ail V in communcc of the granting of this permit
APPLICANT UNDERSTANDS 4ND WILL COMPIN WITH ALL NON-POINT Issued by: Date r�
SOURCE REGULATP^SNS. l 3�71f
Re-roofs j
Signuurt'of Applkanu HAZARDOUS
or v
HAZARDOUS MAngco fo DISCLOSURE Da Type of Roof
Will We applicant or forum Wilding acuPant some or handle havrdma mawritl '
Rued by tic Cupertino Municipal Code.Chapter 9.13.and the Health and Safety
.
Section zs532(a)7 -
C3 Y. '6E All roofs shall be inspected prior to any roofing material being installed.
.0
Will the applicant or future Wilding mcupin use equipment or devices which If a roof is installed without first obtaining an inspection,.I agree to remove
emit heurdous air cmtsminants as denned by tau Bay Amu Air Qnmity Management all new materials for inspection.
Diem?
t]Ya )(No
I haw mad the huardaunuteriaH requirements urecrChapwrti.95 ofthe Uttar.
nu Health&Safety Cale,Secuons25501.25533md25534.iun@�dthuifthc building
does not cuncntiy haw a wont thipt It k my hamotWhllliy to notify We occupant of the
0`uremernsswh�ichmunbOemett WWI a CenfwawafO v Signature of Applicant Date
` —
Owear anuthomsd agent r tAu DIM All roof coverings to be Class'R"or better