05050058CITY OF CUPERTINOR8'
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CON 4
BUILDING DIVISION PERMIT
TRA.CTOR�INVO
BUILDING ADDRESS:
SANTA CLARA VALLEY CORP
PERMIT NO.
05050058
OWNER'S NAME:
PERMIT LEVE DATE
Ee
SANITARY OL N0.
ARCHITECrfENGINEER:
BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
0 0 0 0
LICENSED CONTRACTOR'S DECLARATION
IO Descri tion
P
1 huaffirm eby arm that 1 Am lusted under provisions or Chaps 9 Momordoing
with SoMm. 7") of Division 3 of Me Business and Professions Code, and my license H
in full force end eife
License Z. Lica �,S 844%
DEMO
Data Cmaramr��
-6' /T_ 2005
ARCHrTECrS DECLARATION
I understand my p,ushoUl to used AS public =an&
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B U I LU 11
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Licensed Professional
OWNER-BUILDER DECLARATION
,�� J}/
I hereby that 1 exempt from the Camrscnh License Law for the
fallowing mason. (Suit Tin BualueCo and tiva Calc: Any em Sur county
Maso . (Sc 1.
which) onstr vc. Fi repair tuacturo
"Mics; • Permit re eanmueL abs. imfor
h Permdemolish.
such ed
its signed moment
Olson m its issuance, also requites the applicant for sock permit m
Sq. Ft. Floor Area
ValuaGoo---
on
licensclaw(Clupnr9
licensed the ce
(Olson comms cngwitpScSueatn
ofDivisionfthe the Cass) or
(mmeI. exewits Session 70nd of Division3 of
(commencing
Bed
exemption. Any
Het he I. exempt themfmm and the basis for the alleged exemption. Any vlohton of
al
3 jl ei0
Occupancy Type
forapermit Subjects Ne applicant m a civil penalty of
Se doom
Nm fins hundndapplicant
dollar($500).
❑ I, as owner alum prepmy, or my employee with cages AS their Sun compcnudon,
- Required Inspections
n and He Busitw
does not apply to An
and Professions Calc: The Camador'a License law dues not apply tom owner
a Profession,o CommencesLicensor Law
q P
is
property who buildsor Hereon, and wk doessuch work aelfSur through his
ed thaw
Own employeesprovided or
Innededmplend forthe
provehImprovementsannot
Ower.
Hebuilding ortmprovemenlbmid one Year or completion. He owner
did
killer will have the burden of proving that k did not build or improv for purpose of
Wilda,
SAM.).
1, as Owner of to property. Am exclusively conhaTinQ with licensed conuanan n
come the Business aha Cade:) Tk Conusonh Li.
es not s in whons
cense taw does not apply n an owner of property who builds or improve Haman. and,
La property
who contracts for such projeeu with aeon,mn(e) licensed punwnt to the Contractor's
License Law.
❑Tom exempt undo Sec. ,B&PCfor this meson
Owner Dale
WORKER'S COMPENSATION DECLARATION
I hereby affirm under penalty a(peduryarc of the following declarsdons:
0 I have and will maintain+Certificate of Consent n sel6nswe for Warker's Comped
Codon, AS provided four by Sodom 3700 of the labor Cade. for the performance of the
work for which His permit is iaoed.
0 1 haw and will mainWn WoOere Compmanon lrtsurmce, AS required by Secdon
3700 of the Labor Code, for Ne performance of the wort for which this permit is issued.
My Workers Compensation Insurance Cartier and Polity number an:
Canier..�s �^9.�S�7rb(hlicy No.: y Q& 012 2/k K
CERTIFICATE OF EXFMPT10N FROM WORKERS
'
COMPENSATION INSURANCE
(Thissmaken need nolkcompleted If Ik permit isfor Ono hundred dollen ($100)
.
Or leu.)
1 mdfy Het in He perfor o mo of He work for which this permit is issued, I shell nm
employ any person in my manneran As W become Subject to the Worken•Cominuration
Laws of California. Dam
Applicant
NOTICE TO APPLICANT: If. after making Hla Cenifie a of Exemption, you should
become Subject in do Worker's Compensation provisions of dm labor Cale, you muse
'
faMwhi comply with such provisions or this pe.it.hall k dcemed revoked. '
CONSTRUCTION LENDING AGENCY
,
1 kr Net Here Construction lending agency for the performance of
(Sec. 0
' to work for which 1Ns permit, iado0 face. 709'1, Ci, C.)
which issued
Lenders Name
'
landera Adidas
j I certify that 1 haw mad this pplication and son Ha to above information Is
cO ML I agree to comply with all city and county ordinances and sun laws Mining An
building construction, and hereby mahodm representation or this city to cont upon the
shove-mentioned Property for inspection purposes
(We) agree to ave, indemnify and keep hermits He City of Cupertino Against
j liabilite,judgments.cos, and expenses which may in any way Scene against said City
in consequence of the yon g of this perms.
i APPLICANT UN ERST NDS ANO WILL COMPLY WITH ALL NON-POINT
Issued by: Date
SOU E UL 0
Re-roofs
Type of Roof
q-rf1�/=s
Signatumof Appli VC a �y.SM
HAZARDOUS MATERIALS DISCLOSURE
Will He applicant or future building document nom or handle hazardous manrial
As defined by the Cupertino Municipal Code. Chapter 9.13, and the Hcalth and Safety
Cada. $octan 25532(s)?
All roofs shall be inspected prior to any roofing material being installed.
❑Yu Qac
If a roof is installed without first obtaining an inspection, I agree to remove
Will the applicant O fmure Wilding Occupant use equipmentor device which
It havardous air tmeminams As &r,.,d by the Bay Arne Air Quality Management
all new materials for Inspection.
District? —!
OYea l u
I haw mad the haaNtsmakeris,m luimmems underChap ar6.93 of the Califon
nix Health& Sefcty Can Sodom 75505.33533 wW75534.I undma nd Hetlf de Wilding
does not cunentl haw IMAM. that It 6 my responsibility n Sadly to occupant of the
a mmtsw m Ix:meIimorw usmmofaccrdrmanorGcmpanry.
Signature of Applicant Date
°
All roof coverings to be Class "B" or better
Ow on wed egem Dan