00070113CITY OF CUPERTINO
CONTRACTOR INFORMATION:
BUILDING DIVISION PERMIT
.
BUILDING ADDRESS:
PERNIrr NO.
owNER'S NIM3220 STEVENS CREEK BLVD
APPLICAnrF A17,10 413
ONE H&R BLOCK
SANUAR\'&7 /19 /jE1@1 R N0.
Z ARCHITECIENGINEER:
BUILDING PERMIT INTO
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BLDG ELECT PLUMB MEiCEI
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I_I L =I 1 =1 1.I
z LICENSEDCONTRACPOR'SDECLARATION
Job Description
1 booby affirm that 1 am IicemM under prnvisiunn of Chapter 9 (comm rs, ag
— with Section 71 W) of Dom 13 of the Hoome "and Prolic"ion, C'o[I. and my l icon,,
ull force and lfcc(.
in f e
6 Liccn¢ Class Le, It
Data
INSTALL 1 SINGLE FACE ILLUMIATED, WALL I
ARCIHTEM'SDECLANATION
2 I oodcmland o,y plan, moll be nsc l is padic accord,
SIGN -
Lima%ed Pmmxvcanal
ca OWNER- BUILDCR DECLARATION
1 hereby affirm that I am cxunry from the Contractor's License Law tit the
< following ma I. (Section 70115, ILni ntW Pink,., .. Cud,, Any color ant,
simprove.
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p which requires a permit ro cansanr, , alter. demolish, or repair any snucmre
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= prior to its issuance. also requires the applicant lit such permit In file a signed statement
Sy. Ft. Floor Area
Valuation
- that he is licensed pursuant it) the provision, of Contmcmr, License Law (Chapter 9
(nrmmcncing whh Scroll 7011)) Of Dlvi,ion 3 of the Bushel, and Pmfi,sio t, Code)
or that he is exempt lha,n,'auuntd the Is,, for de rrllr,,d excnmliom Any vioIndia
or Section 9031.5 by ... ... Learn fare Itrmir whjecl, the applacal n, a civil penally
APN Number
Ow Typ
of not room than B.e hundred dollars (S5W).
❑ 1, a,Lwocr of he nropeny, m my mnployce, with wage. a, rhos, sda corrp'n,mfon,
'
Required Inspections
will do Ile work, and the ,nucmrc iv nnl intended or attend her 'Idle (Sec. 71x4.
L.nmrvc Law d
Bovines. and Pmfes,imt, Care, The Commetor, Ply ,, not .. ,, an
r ofh won boils, or improve, at who d «, seen work n
(it
C
such land
ed
ur through his own employees. provided that such improvements are not intended nr
his ,.
offered for vole. IL n it,old one year of
fnc huil0ing or imp,,
,
Of p he ill
nnpininn, nhe owner- builder will nave rLe M1umur al 11rnving Ihaf he AIJ nor build or
,,b.tl c
improve for purpose of sale.).
304 — ROUGH ELECTRICAL
❑ 1. as owner onhe property. am e,vla%aciy contracting with licensed contractor, m
50 ] — FINAL ELECTRICAL ENERGY
,o... all the proicd (see. 7044. Bnsi... , and Pmfe„im„ coded The Contractor,
Licene Law dad and 1,1111, to .11 owner of prapnty who hails, m hnlmv`u,Is,m r'
505 — F I NRL ELECTRICAL -
and who comma, for such project, with a contracm m rt%) licensed pursuant the
Conemr's License Law.
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❑ I am e,mmpt under Svc, . H A P C for this reason
wner Derr
W'ORKER'S COdPENSA'rEON DECLARATION
I hereby al'finn under penally of perjury one of the following declarations:
03omperbation.
I have and will maintain a Certilicate of foment u, xrhmia,urc far Worker's
as provided for by, Section 3700 of the Labor Cars. for the
perfO,manee of the work ILr which this pemtit i, issued.
❑ 1 have and will ma in Worker', Cumpen,miun In,., rmoa u, cquire,l by Scetiou
970) of the Labor Cale. lot the pnlerrnance of the work lit which this .omit is
issued. My Workers Compensaion Insurance Cartier and Policy numMe am:
Carrier', I'ol icy No
.
CERTI IICAI ION 01: 1 I EM PE ION FROM W OR KERS'
COMPENSMiON INSURANCES
(Thin section need urn he completed il'the permit is for one hundred dollars
o ISO ar lass.)
1 certify that in the .crfom once of the work for which this Permit is i„uad. 1
shall not employ any .Cron in any manner or as to become mhjen to the Workers
Cnmpcn,mion Laws of Califu ma. Dwc
A,,eaam
li 10 APPLICANT: IL attar necking this CraU,.m of lhcmpfan, you should
become subject to the Worker's Compensation provisions of the labor Cadc, you must
fonhwhfi comply with such pnwiainm or this permit shall he droned revoked
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q CONSI'RUCI'I ON LENDING AGENCY
1 hereby affect that them is a construction lending agency for the clonmence
of But work for which this permit is issued (Sec. 3097. Cm C.)
Lender's Name
z Lcnder',Alklm,
I rem y that I leave read his application and stale that the above information is
' I agree to comply wits all city and county on inane, and sum laws relating
;) mcorrect
baddingnn,wction, and herchy amhnrim rcprtetmive., Of he city' to rem, open
rnaloo- c- nmmrioned Prolxny r..a cctinn mrpme,.
1 (We) agree I, sane.indmnmity and kccp harudes, the Cal of CUpcnina dgai,l
:n liabiliticz judgments, costs and expen,e, which may in any way name against said
'
Z City in consequence of the germing of this plead,
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON -POINT
Issued by: Date
SOURCE REGULATIONS,
Re -roofs
Signature ul'AppliceMCodomorr u.te
HA]ARDOUS MATERIALS DISCLOSURE.
Will the applicant or future building Occupant ,teal or mmme harradOus material
Type of Roof
s defined by the Culw,I Mmddrpal Oadc, Chapmr 9.12, amt he Health and Sut'ety
Code Saclia. 3592(,)" Cl No
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All roofs shall be inspected prior to any roofing material being installed.
Will the appl ;camarfuturebuildingoccaleaa ,ecgnp,mealardevice,which
If a roof is installed without first obtaining an inspection, 1 agree to remove
nit bamnloun air"ato anu asasda0ned by the Na" Aron Air Oachly Mean "rent
all new materials for inspection. Applicant understands and will comply with
,ntri„9
❑Ye, ❑No
all non -point source regulations.
I have read mu baamdorr, rn ncdxl, mgaimmmtts tutee, Clamer e 95 of me
Coliftem, Health m Safety C:de, Suction, 25505, 25533 and 25534. 1 tmdar,tand rI nl
it the building rice, not currently have a tenant, thin it is my responsibility m notify the
cupant Of the requircrncrus which must be met prior a, issuance of a Cenifcme of
O4,..aney'
Signature of Applicant Date
All roof coverings to be Class `B" or better '
Owner oe aothoriaed .gent Dare