04050173BUILDING DIVISION PERMIT
11TnSn
j 1 understand my plans "I W used u public nxorN
Licensed Professional
OWNER -BUILDER DECLARATION
i2 1 hcmby . (Tmm that 11. exempt from the DOntranCc License law for the
O O
following Iw mown. permit
t ]omm Business and Profession Code: My city of county
$ which its hand • pumit m eotrrtrthe alma, Improve, demnlW, ri e a sig any strueturt
Z'yn prior m its handsome, por o rtquirte the vision[ant fee such permit u Ole a Use (sutame 9
<
that hcuccem, pSeanrm in the Provisions of the oBusomroUceore Uw(CWpter9
,tF B thammene xempwith Satlon Tan d of basis f r of Neeged exe sed Prorcison. My vi Code) tion or
of
3.. Nu io Is campy any applicant tan sed the boar Tori be cts the applicants. My Notation of
Soon sharer by wt' ftedom (• permit' subjects the aPPllesny m a civil penalty of
rwt tame Nan ave hundrtd dollen (25002
❑ Luawbor of Che propmY.mmy employ=withn=unxu sole eompewnon,
and Profess m s Code: The Commencer, Licene law door not apply an an owbor of
property, who builds. Imp. Wreeen, sedwhodonouchwork hirsea for through his
awn employ=. Provided that such ireprovemanu art not friend, oroRemd forWe.lf.
however, the building or improvement Is sold within ors Sea of eompkYon. the owner.
Wilda will have that burGn of proving that be did not Mid or improve for purpose of
nleJ.
❑ 1, as oxner of rix property am exclusively eontea,n{ with licensed toauacurs w
Construct rix project (Sec. 7044. Bwinen and Professions Code:) The Contractors U.
1Se Law.
an, exempt under Sec
.or to the Commerce.
B k PC for this rtasoa
ser Dam
WORKERS COMPENSATION DECLARATION
I thereby grim under penalty of Petjury once of the following daluWOns:
1 W w and will mtinW n •certificate of Covent he self.insure for workerscontain.
Co. as provided for by Second 3700 of the labor Code. for Use perfmmeece, of due
BUILDERS INC IrcoM11ry104050173
Job Description
UNDERGROUND GARAGE 5.,4451
RETAIL 2,506/BLDG "A"
and will maintain Warkeh Compensation Insurance, u eryvirtd by $eeuon
m labor Code, for the peeformanceof Nweede work fee which Pru permit ioluu L
Insurance: Pal
Wtint; x1'Tm2 ��1)� 2 3�OS
fres section bond but be completed Rax permit Is for=e hundred dollars ($100)
a less.)
1 certify that In the performance of dm work for which this permit is issued. I shall not
employ any personmany summer an as to become subject in the Workers'Concannon
Laws of Califomia. Dam
Applicant
NOTICE TO APPLICANT: IL after making this Cerdfiate of Exemption. you should
became subject to the Workers Compensation provistans of the labor Code, you must
.J O forthwith comply with such provisions or this permit shall be domed revoked.
Z tiCONSTRUCTION LENDING AGENCY
PIhereby.Duro that Nem is a construction lending agency for the performance of
a > the work for which this Permit h issued (Seo. 7097• Cry. C.)
L Q lander. Name
Lenders Adder..
V Q 1 ceNfy that 1 have rt, this application and sum thin the above Information Is
L4 t"! Cormtt I Mine ve comply with all city and county ordinances and sum lave Citing m
p rV' building construction, and hereby anthodw representatives of this city to enter upon Ne
above-mentioned property for Impaction purposes.
(We) agree to save, indemnify and keep harmless the City of Cupertino against
ver Cat Ilabilines, Judgments, cons and expenses which may in soy my acerse against Card City
(,) 7 in consequence of the &cutting of this Permit.
F7 APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON -POINT
handle heyadme maudal
and the Health and Safety
Area
31620084.00
Issued by:
Re -roofs
Type of Roof
Required Inspections
NO.
Date
7
Code. Section 25572(a)] All roofs shall be inspected prior to any roofing material being installed.
❑ Yu
WIII f applicant ore Tatum building occupant saw cyutperi or devices which If a roof is installed without first obtaining an inspection, I agree to remove
mit heurious air conumitunts as dcOncd by No Bay Area Air Quality Management all new materials for inspection.
District]
❑Y.,
I haw rend the hasdons materials royulromonts under Chapter 6.95 of the Caliier.
eta Heal" SafelyCode, Sectors 8505.25533 and 23574.1 understand Ilut lfNc building
d= not curteIttry hew a unset. Net It is my reeponslbillty in wdfy the occupant of Ne
myuirtmcnta which muss be mel�w�) uuteetr. eeNne,te ar Ocapaney. Signature of Applicant Date
r%/✓�f�r/%� All roof coverings to be Class "B" or better
Dw"a ��..��r � Date