05010152CI TY OF CUPERTINO
/v �'�`**T?�r'ye.y.� wee''. �'�ia` '`,� -t'
BUILDING DIVISION PERMIT
tA+Ot\TRAG-Tl/RANEONATION.
BUIL DING ADDRESS:
PERMIT N0
05010152
EWS NAME:
PERMIT ISSUE DATE
ARCADIA DEVELOPMENT
E:
SANITARY NO. CONTROL NO.
ARCHITECT/ENGINEER:
BUILDING PERMR INFO
BLDG ELECT PLUMB MECH
LICENSED CONTRACTOR'S DECLARATION
esarl
Job Description
1 hereby air,,. shat 1 un littmud under provisions N Chapter 9 (commencing
p
wish Section 7W0) of DlvIslas 3 orthe Business and Professions Code, and my license Is
In full forte and eflttt z
S X773
TI --3 OFFICES/BREAK .RM
License Clsua
Dam contractor
CONTRACTOR:. LYNSTAR ENT E� bI�NF7r%
ARCHITECTS DEC
��°°s
I underatand my piens shall he used a public meet&
(�
2[105
APR 2(�
Licensed Professional
OWNER-BUILOERDECLARATIONContrContractor's
Lice
I hereby AM. that 1 em exempt from the Contractor's Lew for the
following reason. (Section IIA 1.5, Business and Professions Code: Any city or county
which requires a Permit m construct, eller. improve, demolish, or repair any ewcturn
pilar initsIteumec. al. rcyulme alp: applicant for each Permit to rile a signed statement
that he is licensed pursuant to the provisions oflhe Contractor's Umnw Law (Chapter 9
Sq. Ft. Floor Area
(.ppp.
(commencing with Session 7000) of Oivisian 3 of the Ousincu and ProfasinMCode) ser
I
Nal he Is ...,I therefrom and.Ne buts for the alleged exemption. Any violation of
ppN Number Occupancy Type
Section 7031.5 by any applicant for a month subjects she applicant to a civil penally of
not mom Nan rive hundred dollen (S500).
37501022.00
❑I.uowneroflhepmKny,ormyemploycawlNwaguuNcirwlccompenudon,
Required Inspections
will do the work,and the swelum B not intended m offered foraale(Sce704a Businms
and Prefesslone Code: The Conuactoes Lim. Law does noI apply to an .cone, of
q p
pmpeny who builds or improves thereon, end who does such work himulfar lhmugh his
own employees, provided that such improvements ve nut inmMed ooRered for tile. If.
however, she building or imprevemenl is cold within ane yeti of completion, the owner -
builder will have the burden of proving that he did not build or improve for purpose or
tile.),
❑ I. as owner of de ptopeny, am eacluivcly contracting with licensed contnmon to
construct the Project (Sec. 7044, Business and Professions Code:) The Conuams's U.
cense Law docs not apply to an owner of pwpeny, who Wilds or improves thereon, and
who concocts foe such pmjeax with amouraemr(s) licensed pursuant a the, Convectors
License law.
❑ I m aexempt under Set ,B&P C for this resume
or Dale
WORKER'S COMPENSATION DECLARATION
I hereby anon under penally of perjury one of the fallowing declarations:
IMve
and will maintain a CeNOcam of Consent m self -alum for Worker's Compen-
ation, u provided for by Section 3700 of the Labor Code. for the performance of Nd
work for which this petrol[ is issued.
❑ 1 have end will maintain WeakeM1 compensation Insurance. u required by Section
3700 of the Labor Cade, for the, performance of the work for which this permit is issued.
My Workefa a�m1pemai Intone certicr end Polley n�um�M�r(�L)c/�'�'
Cartier, rt5c GAJ Polity N0.: {m2L
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(Thksectlno need not beemopletcd If the Permit Is fmow hundmddollan ($100)
or ksq
I certify Nm In the performance of the work for which this permlt Is issued, l Nell not
employ any person In Ny AOAMT m As 10 become Subject to IN WOflXr CDMNMallan
Laws of California. Dsuk
Applicant
NOTICE TO APPLICANT: IL after making this CenlEam or Exemption, you should
become subject no the Workefs Compensation provisions of de Labor Code, you muse
forthwith comply with such pmvisiou o this permit Nall be damed revoked.
CONSTRUCTION LENDING AGENCY
I hembY afrnm Nal Nem its eonmuetion lending agcnry for the perfoma=ur
the work for which this permit is issued (Sec. 3097. Civ. C.)
-
Lender'e Name
Iander'sAddress
I ttnethat 1 have tad Nis application and sum Nes the above information is
building 1 agree to comply with all city and county and sum levee relating
e
of this city to enter upon the
building construction,ti.mecod hereby natives Of Upt
mdO.IOmpmxnmivv
purposes
above-mentioned Properly for emnify
/
an Against
agree to arc, indemnify and http hay the City of
(s
/ y
in an against
Iiabilitlds,Judgmcnu,coN and expenses which may in any way eccmd against aid City
judgments,
in co uencoa gra (this permil.
APPLI NT U ER AN AND WILL COMPLY WITH ALL NON -POINT
Issued by: Date 4/ YL/ v�.•l
SOURC ECU N5. ^n` ��
Lb
Re -roofs
Type of Roof
Signature of Applian✓Conuacsor Dam
HAZARDOUS MATERIALS DISCLOSURE
Will Me applicant Of future building ocupant atom or handle ha ammus material
a dented by the Cupertino Municipal Cade. Chapter 9.17. and the Health And Safety
Section 75537(x)7
All roofs shall be irispected prior to any roofing material being installed.
C] Yes ❑No
If a roof is installed without first obtaining an inspection, I agree to remove
Will the applicant or future building occupant use equipment or devices which
troll hanrdous air contaminants As defined by the Bay Area Air Quality Management
all new materials for inspection.
District?
Oyu ❑Nu
1have mW the lo, ,us materials requirements undcrChapter 6.95 or the Califon
nice Hcai &Sare IyC Guns 75533 and 25534.1 understand Nst if the building
docs not c orally ha a moan Ail i my respoMlhillty to notify the occupant of the
requirement whichm Is, 1pnarmiss anmafa CeniBatesur Occupanry.
"2(0-05
Signature of Applicant Date
_ �
All roof coverings to be Class "B" or better
Owner
or aushadmd spool Dam