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CITY OF CUPEWrINO
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BUILDING DIVISION PERMIT
C01vTRAC-TOR INFOkMAT,II
BUIIn1NcADDRESS:
PACIFIC GENERAL CONSTRUCTSSU
Ill "'03080080
NER'SNAME: -
38350 FREMONT BLVD
FIRWIT ISSUE DATE
D"E'
(510)713-9343
SANITARY N0. CONTROL N0,
ARCHITECT/ENGINEER:
BUILDING PERMIT INFO
BLDG ELECT PLUMB MF.CH
LICENSED COMTIACTOR'S DECLARATION
1 hereby affirm that 1 em licensed under provisions of Chapter 9 (commencing
` Job Description
With Section 71)l of Division 3 of thd Business and Pmfcrsionv Coda, and my liccnsc is
in full emo.nd cffecl.
License Clan Lic.N
Dale Contracts
ELECTICAL F '.S ELLS%B
: h
ARCHITECTS DECLARATION
IundcrsanJ my plans shall kused as puttee records
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Licensed Professional
OWNER -BUILDER DECLARATION
I hereby affirm that I am exempt from Ik Contractor's License Law for the
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follawing reason. (Seomm 713 1.5, Business end Profeuiov Code: Any city lir county
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Which requires a permit to cnnstmn, alar. impmw, dcmniksh. or repair any immune
in onto its issuance. also requires; the applicant fee such .it,. File a signed statement
that he is licensed pursuant the provisions otter, Contracture License Law (Chapter 9
Sq. Ft. Floor Area
ationr
(commencing with Section 71100) of Division 3 of the Business and Professions Cole) or
that heti exempt therefrom and de huffs for ft alleged exemption. Any violation of
36906010.00
APN Number
Occupancy
P y Type
Section 7031.5 by any applicant ton permit subjects the applicant to a civil penalty, at
not more than Bw hundred donors (55(01.
❑ I, a owner of the property, or my employe" with wages u their sole compensation,
—
will do the wart. and theswcturt I, or intended or offered for sale Deh. 70", Business
wd Profrsamns Cade: The Contractor's Littue Law da" not apply in an owner of
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property who builds orimprows thereon, and who daessuch work himself or through his
- FINAL ELE CTR I AL
own employees, provided that such improvements are not Intended or dilated for sale. If.
505 — FINAL ELECTRICAL
however, tus tuilding or imprewmem Is sold within one year of completion. Ne owner.
Wilder will luso the burden of proving Nu be did ads build or Improve for puryve of
aypo L
q-1, as owner of the property, am exclusively contracting with licensed contractors to
coutmct the project (Sec. 7004, Buineu and Profeuions Cade:) The Contractor's U.
cove law it= not apply Or an owner of property who builds or improves thereon, and,
who coursers for such pmjccu with a contnctar(s) licensed pursuant to the Contractor's
License I.
❑tem un tt. ,B/&P for thbr uon
T
au
COMPENSATION DELL ION pi
J
1 ban"' alEnn under penalty of perjury one of the following dedualone:
1 haw and will maintain a Certificate of Consent to elf -insure for Worker's Compen.
station, u provided for by Section 3700 of the labor Cade, for the performance of the
work for which this permit is issued.
❑ 1 ban and will maintain Worker's Compensation Insurance, u required by Section
37110 of the later Cade, for the performance of the work for which this permit is issued.
My Worker's Compensation Insurance cartia and Policy number am:
Cartier. Pdliry No.:
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(This secOnn need Out hccomplmed if nbe permit ie for one hundred unllars DfUl
or leu.)
I certify that in the performance of Ne work for which this Permit is issued, I shall not
employ any person is any manner w as M khnme subject to the Worker' Compenudon
Laws of California. Der,
Applicant
NOTICE TO APPLICANT: If, after making this certificate or Exemption, you should
become subject o the Worker's Compensation provisions of me labor Code. you must
forthwith comply with such provisions or this Permit hall be deemed revoked.
CONSTRUCTION LENDING AGENCY
I hemby effrrm that there is a construction lending agency for the performance of
Ne work for which this permit is issued (Sec. 3097, Civ. CJ
Lender's Name
landeri Address
I Certify Na I haw read this application and sure Net the own information is
correct I agree to comply with all city and county ordinances and sone laws relating to
building construction, and hereby adlumim mpresenotiwaof this city to enter upon the
ahove-mentioned property for inspection Purposes.
(We) agree to sew, indemnify and keep harmless nee City of Cupertino against
liabilities, judgments, casts and expenses which may to any way theme against aid City
in conaq nee r the granting of this Permit
AP NT T NDS AND WILL OMPLY WITH ALL NP INT
Issued by: Date I
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Re -roofs
ignsfidaliAppiica B ono rD e
HAZARDOUS MATERIALS DISCLOSURE
Type of Roof
Will Nc applicant or future building Occupant sore or handle havallous material
u deFined by the Cupenino Municipal Code, Chapter 9.12, and the Health and Safety
Ja, Ser cltiion ea 25532(x)?
All roofs shall be inspected prior to any roofing material being installed.
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If a roof is installed without first obtaining an inspection, I agree to remove
Will the applicam or forum building Occupant use equipment or devices which
h minnows air contaminants u dcrined by the Bay Area Air Quality Menagcmcm
all new materials for inspection.
ulet?
❑Yes Yt u
I have mail the haurdous materials mquirtmenu under Chapter 6.95 of the Califor-
niaHcalth65nfety ode, Sectiuv25505.25533wd25534.1undernand NairNe Wilding
odea not y w n an it is my respovihility,. nam l'y tk me pant f the
regaire hie n ridrw oar r c ate drOccd r.
Signature of Applicant Date
All roof coverings to be Class "B" or better
own
rat hviacdagert ate