04050152 CITY OF CUPERTINO
BUILDING DIVISION PERMIT CUNTRe1CTt1T2 INY'OVIr�TION� .'
BUILDING ADDRESS: GREATER BAY CONSTRUCTION PERMIT ND.04050152
106
OWNER'S NAME: PERMIT LSSUEDATE
GB ESTATE HOMSE SUITE 200 05/2q,/2004
SANITARY NO. CONTROL NO.
(408) 248-6600
ARCHITEC(ENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
t� 0
LOp LICENSED CONTRACTOR'S DECLARATION
MU� I Weay affirm don 1 am licensed under pm
ellim,of Chapter 9(commencing Job Description
n�2 with Section 7000)or Division 3 of Me Business and Professions Code,and my license is
ora in full to=Clus effect, REVISION--IN HOUSE USE ONLY
j License Class N
Lic.
nt— Dme Comu¢tar NO NEW PERMIT ISSUED ORIG. #03110113
YARCHITECTS DECLARATION
Y 32 1 understand my plans shill M used as public records
6
;Q� Licensed Pndcssinnal
S OWNER-BUILDER DECLARATION
E<0 1 hemhy alum(Section n I am exempt(rum Ne Cununctor's e:Any c Lew for thy
p o following roman. ermiI ](131.5,Business and improve,
deimu Cad.:Any city or county i
E which requires n permit to mires TThe alter im for such
ddmoltsh, file
repair any merican
priormiucensed ealmmquirm previsionapplicoffer Connetoitmicense ned Law(chapter
—=< that heislic.nmdpursuanunthe pmvisiomofNcConuumrYLiccnselaw(Chaptcr9 Sq.Ft. Floor Area Valuatio107
z0 (commencing with Section 7")of Division 3 of NC Business and Profession Cmle)or
g59 that he is exempt therefrom and the been for the alleged exemption.Any violation of
Section 7031.5 by any applicant for a Permit subjects the applicant to a civil penalty of APN Number Occupancy e
not more Nn five hundred dollars($500). P Y EYP
01.as owner oftbe properly,or my employees with wages As Noir sole comrmsemen, 35922074 . 00
will do the work,and Ne swcwre is nut intended or offered fonale(Sec.7044,Business
and Professions Code:The Cmernmtors Leon.Law data not apply In an owner of Required Inspections
property who builds or improves thereon,a nd wheaten such work hineself or through his
own employes,provided that such improvements are not intended oroRercA formic.If. C\
however,the building or improvement is sold within one year of complemin,the owner.
Wilder will have the burden of paving that he did net build or Improve for purpose of
ale.).
I1,ra owner r Ne property,.B sin m and contracting with:)This Coanauton i.
o wet the projem(Sec.]044.Bminess end Professions Code:)The Contractor's Li-
me law docs not apply tan owner of property who sed p or improves thereon.and,
who contracts for such projects
nt
with a eorutor(s)IianxO pursuant to Ne Contractor's
License Law.
❑lam exempt on cc. .Bk PCf IN mason
Owner Data
C:R'S OMPENSATION DECLA O
emby ❑w under penalty of perjury on of Ne full ng materialism:Va
hers nd will maintain a Certificate ofCommil to self-insure for WorkctsCompen-
sation,as 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 Worker's Compensation Insurance,as required by Section
3700 of Ne labor Code.for the performanm of arc work for which this permit is issued.
My Worker's Compensation Inaumtem,exericr and Policy number are:
Carrier: Policy No.:
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(This section need not be completed if the permit is forum hundred dollars($100)
or less.)
1 certify Nal in the performance of Nc work for which this permit is issued,I shall not
employ any person in my manner so as an become subject an ate Workers Compensedon
Laws of Califomin Dat.
Apid!cut
NOTICE TO APPLICANT:If,after making this Cdnificaw of Exemption,you should
became subject an the Worker's Compensation provisions of Ne Labor Code,you must
,J 0 forthwith comply with such provisions or this permit shall be darned twice.
Z► CONSTRUCTION LENDING AGENCY
'[~r I hereby affiw Nat Mo.is a eminmction lending agency for the performance,of
(Yi .>-i Iho work for which Nu permit is issued(Sm.3097,Co,C.)
Ut)Q Lender's Nine.
a Lender's Addoes
Q I certify that I have read this city
and coup and sate Net and
nbaro information is
0 U building 1 agree to comply with all city and county oNinmea and cute laws relating e
0 V iday.ngconstruction.imenm0 hereby aune.p rmse. utivrs of this city to toter upon Nc
ILl above-mentioned progeny for emnify an keep he
gy (Wc)agree to cove,indemnifyandkap hay in
Ore Cityru Cuainstsagarol
y
liabilities,judgments,the
and expenmamitch may in anyway accrue againstmix City
Uz in cen'um"c ' gArea oft- permit.
APPLICA DER ANDS AND WILL COMPLY WITH ALL NON80INT Issued by: Date
S ERE LA S.
�Z5 Re-roofs
,sadnature A HAZARDOUS MATERIALS DISCLOSURE Da \ Type of Roof
Will dm applicant m future building occupant store mimetic hamolous rr�jg�aI
As defined by Ne Cupertino Municipal Cade.Chapter 9.12.and the Health and Safety
Code,Sixtion 25532(.)? No All roofs shall be inspected prior to any roofing material being installed.
CycA
Will the applicant or .dura building occupant use equipment or devices which If a roof is installed without first obtaining an inspection,I agree to remove
I havardnes air contaminants as defined by the Bay Area Air Quality Management all new materials for inspection.
District? �5
C]Yen 6^u
1 have mad the hamohnials m ineuds requirements under Chapter 6.95 of the Calif.,.
.I.Hmob&Safety Cattle,Side.25505.25533 and MM.1 understand Nm if Nd building
does not cu have tenant,Net It is my responsibility w nodl'y Ne mcupml of Nc
rayeats ch At be met prior in!.ama of a Cerdg Icor upmry. Signature of Applicant - Date
Owter er t .' dageni Ie All roof coverings to be Class"B"or better