03120106CITY OF CUPEATINO
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BUILDING DIVISION PERMIT
eONTRACTOIi
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BUILDING ADDRESS:
MENEMSHA DEVELOPMENT GROUP
PERMITND.03120106
OWNER'S NAME:
PERMIT ISSUE DATE
H
E;
V(310)343-3
30
SANITARY NO. _ CONTROL No -
ARCHITEC ,ENGINEER:
BUILDING PERMIT INFO
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BLDG ELECT PLUMB MECH
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LICENSED CONTRACTOR'S DECLARATION
Job Description
O I
1 hereby affirm that 1 am licensed under pro visions of Chapter 9 (commencing
p
with See )of DiviaiW3of the Business end r'. on, Code,and my license is
^nd
m rmu. r L
REVI - -IN HOUSE USE ONLY
Licenu aza Lic. N
Dam ' - - em ^tree
NO_ NEW PERMIT ISSUED /ORIG. #03110074
ARCHITECTS DEC
1 un rstand my plans shall M used as public records
Licensed Professional
OWNER - BUILDER DECLARATION
1 hereby affirm that I am exempt from the Contractor'& License Law to, the
following reason. (Section 7031.5, Business and Professimu Code: Any city or County
which requires a permit to construct, alm. improve, demolish, or repair any structure
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Poor to its issuance, also requires the applicant for such permit to File a signed statement
that he is licensed pursuant to the provisions of the Contractors License Law (Chapter 9
Sq. Ft. Floor Area
Valuation $31
(commencing with Section 7") of Division 3 of the Business and Professions Code) or
that he is mcmpt therefrom and Om basis for the alleged exemption. Any violation of
APN Number
Occupancy
O e
TYP
Section 7 031.5 by any applicant for a Permit ubjects the applicant o a civil penalty of
not more than me hundred dollars Won).
Y
37506007.00
❑ I, as owner or the progeny, or my employees with wages AS their sole compensation,
Required Inspections
will do the work, and the swan¢is not intended .,offered el.tde(Sm. 7014, Business
and Proftessiona Code: The Connector's Licenu Law does not apply to an owner of
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property who builds or improves ismomand who doesmch work himself or through his
own employees, provided that such improvements are not intended uroffered formic. If.
however. the building or improvement is sold within one year ofemadmion. the owner-
belltla, will have Be, bond.. or proving duel he did net build or improve for P.I. of
/aa
J
1, as owner.( the progeny, am contracting with licensed contractors
C] 1.
❑
and
..mesa the project Business and Professions Code:) The Contractors i
sinus PmfCSS
\
w Boca not uch ply to an of progeny who or Improvers and
apply an emon, nd
with a the
who Cor for such pmjecu with a.onlncmr(s) licensed pursuant m the Conmecmis
who Coroners licensed
Lacta
LkI Law.
❑ 1 em exempt under Sec. , B k P C for this reason
An
,
Owner Doe
WORKER'S COMPENSATION DECLARATION
I hereby affirm under penally of perjury one of the following declarations:
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ave and will maintain a Certificate OfComenl to self -insure for Worker'sDampen-
mtion, as provided for by Section 3700 of the labor Code. for She performance of the
work for which this permit is issued,
❑ I have and will maintain Worker's Compensation Insurance, m required by Section
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3700 of the Labor Cotle, for the performance of the work for which this permit is issued.
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My Work Compenmrion 1. use icrand Policy numbcram-
Carole - Polley No
CERTIFICATE OF EXEMPTION FROM WORKERS'
'
COMPENSATION INSURANCE
(Thu sent.. need nod M complemJ if the permit is (.none hundrttl dollart (ilIXl)
or less.)
1 curtify Nat in the perrormaceeOf the work for which this permit Is issued, 1 shall or
employ any person in any manners^ as m become Subject o the Workeri Compcmafion
Law, of California. Date
Applicant
NOTICE TO APPLICANT: IL after making this Certificate of Exemption, you should
become subject to the Wmkces Compcneetion provisions of the labor Code, you must
forthwith comply with such provisions or this permit shall be deemed revoked.
..
CONSTRUCTION LENDING AGENCY
I hereby affirm that Vert is a construction lending agency for the performance of
the work fur which this permit is issued (Sec. 3097, Do, C.)
Lendse. Name
_
Lender's Addrem
I certify, that 1 have read this application and stem that the above infom ation is
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correct. l agree to comply with all city and county.Ninmces and Siam laws relating to
building construction, and hereby amhOriM representatives of this city to enter upon the
show- mcntiuned properly nor inspccdon pno,gaea.
(We) agree to save, indemnify and keep harmless the City of Cupertino against
liabilities, judgments, costs and expenses which may in any way accrue against said City
in commiluence of the granting of this permit,
APPLIC NT DNDERSTA S AND WI CO Y WITH ALL NON -POINT
Issued' by: Date
SOUR REGULA
/1-11 -
Re -roofs
Type of Roof
at of ApplicanVCOmract., Data
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future building Occupant store or handle hansrdous motional
AS defined by the Cupenin^ Mon cipal Code. Chapter 9.12, and the Health and Safety
Code, Section 25532(.)? No -
All roofs shall be inspected prior to any roofing material being installed.
If a roof is installed without first obtaining an inspection, I agree to remove
Will the applicant o, fist re building av:upam tau equipment or Jcvices which
hazardous air comamirmts u defined by the Bay Area Air Quality Management
all new materials for inspection.
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❑Yea ❑1�1—
I have mad the hanodousmaterials mquimmenu under Chapter 6.95 of the Cuiror-
nia Health A SafetyCOde, sections 25505,25533 and25534.I undersmnd th adthe building
does noME a mnant. Net i is my responsibility m notify the..Part nr the
roon etp'o i :s ceoraeenircam acupan.r.
Signature of Applicant Date
All roof coverings to be Class "B" or better
cd aFCm Dam