03120017 CITY OF CUPERTINO
BUILDING DIVISION PERMIT CONUUCTOR,INk'ORMA'.�ION :
BDILDINGADDRESS: MISSION DEVELOPMENT CORP PERMITNO03120017
OWNER'S NAME: - PERMIT ISSUE DATE
PALAN
E: SANITARY NO. CONTROL NO.
(510) 657-4777
ARCHITEC(ENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
D o LICENSED CONTRACTOR'S DECLARATION
I hereby affirm that I em lisnmed undo,provisions of Chape,9(commence, Job Descriptio
�BE with Section 7")of Division 3 of NC Business and Profeuions Code,and my license is FINALED
j�? inmufomoardermD`' ADDITION 252 SQ. FT. /REMODEL
LicenseClass La.X
�� Date Contractor � ter_ 1.
Q�Q ARCHITECTS DECLARATION - QI'r /Z 2004
i a� I understand my Plansshall he used as public records .
D O x Licensed hereby Professional BUILDING
OWNER-BUILDER DECLARATION
+�a 0 1 booby.(Sero that I am exempt(rum the Contractor's License Law for the
p o following moon.(Saito 8onstr Business, tand improve,
a demolish.
Code:Any city or county
which requires a permit ralso e construct,pimp improve,demolish. fierepair anygned statement¢i primus its tensed grsuant In the the
ovisio antsur forsucthe Cohrctoiuoicense Law
sotcmem
(commecing wit pursuant In of Division 3 the Comracerand Professions
Cod
mr9 Sq.Ft. Floor Area Valuation
(commencing with Section 7")of Division3 of the Businessandon.Ani bCode)or
Net he B exempt therefrom and the baso for the alleged exemption.Any vinlallon of wi
Section 7031.5 by any applicant for a Mind,subjecu the applicant a a civil penalty of 3 G"I�,wgs yV LDIL�f`
ero O Occupancy'+ e
not more Nan Eve handmd dollars(S500). P y I7P
I,as owner of the property,or my employees with wages as their sole compensation,
will do the work end On,slructare isnot intended or offered for sale(Sec.7044,Business
and Professions Code:The Contractor's License Law does not apply to an owner of Required Inspections
progeny who builds or improves thereon,and who does uch work himselfor through his
own employees,provided than such impmvemcnu are not intended or offered for sale.IL
however,Ne building or improvement is sold within one year of cemplowst.Ne ownco-
builder will have the burden of proving that he did not build or improve for purpose of
.in J.
types,,1,es be,of On property,am exclusively counting with licensed c.nMet..a
ldnstmct the project(Sec.7044,Business and Professions Code:)The Contractor's Li.
comm Law does not apply to an owner of property who builds or improves daemon,and
who contracts for such projects with a contractor(s)licensed pursuant to the Contractors
License Law.
❑lame astenders.. ,B&PC rthlrs rcmon
O nor Date I Ir•O _
W RKER'SC MPENSATION DECLARA
I hereby aRrm under penalty or perjury one of the following dedareiers: -
1 have and will maintain aCertificate of Consent to self-insum for Worker's Compcn.
author,as provided for by Section 3]W of the Labor Code,for Ne performance of the
work for which rota permit is issued.
❑1 hove and will maintain Worker's Compenamion Insurance,as required by Section
3]00 of line Labor Code,for the performance of the work for which data permit is issued.
My Workers Compensate.Imu m e,carrier end Policy mOr k,art:
Cartier: Policy No.: _
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(Thu section need not be completed if the Permit is for one hundred dollars($]00)
or less)
I certify Nat in the performance of the work for which this permit is issued,1 shell not
employ any person in any manner so as to become subject to the Workerf Compensatlon
Laws of California.Data
Applicant
NOTICE TO APPLICANT:IL after making this Certificate of Exemption,you should
become subject to the Workers Comp co scion provisions of the Labor Code.you must
0 O forthwith comply with such provisions or this Permit hall he deemed mocked.
,z.t(Z) CONSTRUCTION LENDING AGENCY
[—� Ihereby cnrm forthereI issued( ec.30 lending agency for the performance of
a -c murk for which this permit is issued(Sec.3097,Civ.CJ
QI<nders Name
Lender's Addreas
C)Q 1 cenify that I have read this application and state that he above information is -
IL correct.l agree to comply with all city and county ordinances and state laws misting to
O(, building conswetion,and hereby authorize representatives of this city to enter upon the
>" above-mentioned property for inspection purposes.
(We)agree to save,indemnify and keep harmless the City of CupcninD against
HN liabilities,judgmenu.cosu and expenses which may in anyway seems,against said City l
in
of the granting of
U"^
APPLICANT eUNDERSTANDStAND WILL COMPLY WITH ALL NOWPOINT Issued by: Date/,
SOURCE REGULATIONS.
il/ !"� L- /A I I y'( y Re-roofs
tures(Applic ommce Date
CZARDOUS MATERIALS DISCLOSURE Type of Roof
Witt the applicant or future building occupant atom or handle haaardous material
as defined by the Cupertino Municipal Code.Chapter 9.12,and the Health and Salary
Code,Section 25532(a).'Yea No
All roofs shall be inspected prior to any roofing material being installed.
'r�
Will clic applicant or future handing occupant use equipment or devices which If a roof is installed without first obtaining an inspection,I agree to remove
,It ha annus air contaminants a defined by the Bay Area Air Quality Management
barrier? all new materials for inspection.
❑Yes 'Nd
I have read the havrdnusmaariau requiomenu under Chapter 6.95.(the Calif.,
ol ileaW&Safety Cede,Sectors 25505,25533 and 25534.1 understand thatifmc building -
does not currently haw a anent,that it to my responsibility to nudly the occupant of dam
ayvirtmcnu which must he mlPb or or issuance of Ccnif¢aa of Occup hey. Signature of Applicant Date
P 1 �sj'
Owner Cr ori ,xi ager, Das All roof coverings to be Class "B" or better o