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CITYOFCUPERTINO
BUILDIN DIVISION PERMIT
,CONTRACTQRRINF 'RMAZIO
U RESS:
PERMIT NOO 5 0 6 0 0 14
028 STEVENS
Its NAME:
PERMIT ISSUE DATE -
DR. HENRY LIN
08/10/2005
NE:
SANITARY NO. CONTROL NO.
ARCHITEC (ENGINEEK:
BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
o o
LICENSED CONTRACTOR'S DECLARATION
Job Descriptio
1 hereby allirm that I am ficerued under Provisions of Chapmr 9 (commencing
a
with Section 70110 of Division 3 afNe Busims and Professions Code, and my licean b
In fell force W effect.
Lieerrxe ciao Lte.g
Dow Contractor
TENANT IMPROVEMENT - PARTITION
NEW CEILING /LIGHTING ETC. A�
ARCHFMCrS DECLARATION
I mlaermanA my shall he used u ranrda
plans public
glid ,o �+o ?ODc
Liccnud Pmfmtonal
OWNER - BUILDER DECLARATION
�J 1 a/
Ago
I hereby Affirm that I am exempt from she Connector, License 4w for the
following 70313, Bwiaas W Professional Cale: Any
1`SpTJIrJ
reason. (Section city or county
t
•F
which mquirn • permit b cowrun, alto. improve, demolish. or repair any structure
dl j ; j �,pyt,
prior an its issuance, *am requires the applicant for such permWo file a signed statemem
that he is licensed W the the conlracmre Wxae LAW (Chapter 9
Sq. Ft. Floor Area
- y
aVtillt 236
pursuant provision of
(commencing with Sentient 7000) of Division 3 of alto Burman, and Pmfrsaimu Code) or
�'-
that he in exempt tkmfran and the basis fa the alleged exemption. Any violatfon of
APN Number
Occupancy Type
p y yP
Section 7031.5 by any Applicant for a permit ubjects she applicant to a civil penalty of
trot more ham five laurelled donor (SSOM
37511071. 0 0
❑ 1, u owner of she property, or my employees with wages as their Able compensation.
Required Inspections
intended cropland! for
lapply 7�'ow`ner of
And Prnferwiero Code The Law does but
property, who builds or improve thereon, end who does such wag himself or through his
own employee, provided thatmch improvemmt are net intended oroRered fmssla If.
however. the building or improvement Iamld within ore Sear elmmpletiov. the owty-
builder will have the burden of proving that he did not build or Improve for purpose or
"Is.).
owar of she property. Am exclusively compacting with IlcetuW contractor m
met the Pmlect (See. 70"4, Business and Professions Code:) The Contractor's Li-
paw does not apply o an owner of property who builds or Improve shores. and,
onumts for such Projects wish a contractors) licensed potmant to the Con sere.
e law.
meemptundi sec. .BAPCfor is
in
ri CC Date
OMERB OMPENSATION DECLARATION
1 hereby ninon under penalty of perjury our of she following
ave m it will maintain a Cerdficate of Consent an self -imunc far WoraeM1Canpen.
union, As provided for by Section 3700 of the labor Cade. fa the performance of the
woic for which this permit Is issued. ,
❑ 1 have and will maintain Wager's Compensation Insurance, as required by Section
3700 of she labor Code. for the performance of the wort for which this permit is itAad.
My Worker's Compensation Insurance carrier and Policy number ere:
Cartier: Policy No.:
CERTIFICATE OF EKEMMON FROM WORKERS'
COMPENSATION INSURANCE
(This Auction need matucconpleted Ifthe permit is ram hundred dollars ($100)
or lca..)
I canify that In the performance of the wag fee which this permit is issued. I still oat
employ any Person in any maPncr Aba3 toe JObjm3JO tho Workers Compem adon
Laws of California. Date
APPH.
NOTICE TO APPLI ter n Cartes of Exemption. you should
become subject to the car mpen on provisions of she l.ahnr Code, you mum
foMwith comply with such provisions or this permit shall be doomed revoked.
CONSTRUCTION LENDING AGENCY
1 herehy a1Rrm that there is • cerrmrbetin t lending agency (or the perfurmmm, of
the work Can which this permit is (ssucd (Sec. 3097, Cn. C.)
Lender's Name
Lenderi Address
i certify that 1 have read this application and saw alw she above infomadun is
correct. 1 agree to comply with all clay and county ordinances and state laws totaling to
building convection, and hereby &uthaaim representatives of this city w color upon she
&hove- mm0oxd property for inspection purposes.
(We) agree to save, indemnify and keep harmless the City of copulation against
Ilebilida, judgment, emu and expmue which may In my way &cane &gamut said City
in consegmrwe of tic granting of this permit.
APPLICANT NDERSTANDS 0 WILL COMPLY WITH ALL NON -POINT
Issued by: Date
SOURCE RE ULAMONS.
Re -roofs
Type Of Roof ,
emptan or Date
HAZA OUS MATERIALS DISCLOSURE
Otlwapplkem future building o cupant more calculate huudour material
Recd by the CupeNno Municipal Code. Chapter 9.12. and she Health and Safety
e, ScNcn xs532(07
All roofs shall be inspected to any roofing material being installed.
❑ Inc. No
prior
If a roof is installed without first obtaining an inspection, I agree to remove
Will she applicant or future building occupant use equipment an devices which
mlt halmmus air cmuutinants ss donned by the Bay Arta All Quality Management
all new materials for inspection.
DisuktT
❑Yca Nu'
I have reW the Wcarders materials mqulremenu under Chapter 6,95 of she Cabral.
nix Health alt Safety Code, Sectiau x550s.x 533 and 23334, l understood dot If the building
l h' my to ratify she occupant of she
does re curtenhich
t ace, f Ccity
mimre wntemm�mhemetpriar tssuanceaflCeNBcate*r
Signature ofApplicant Date
pp
� Pe
All roof coverings to be Class 'B" or better
g
Ownn.pr v
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wthorvted a em te