06030160CITY OF CUPERTINO
IN,O,RM.4TION •',
BUILDING DIVISION PERMIT
.�CONTRAGTnR
BUILDING ADDRESS:
PERMIT NO.O 6 0 3 0 16 0
19622 STEVENS CREEK BLVD
OWNER'S NAME:
PERMIT ISSUE DATA
OM BIZ INC
05/25/2006
E:
SANITARY NO. CONTROL NO.
ARCHITECT/ENGINEER:
BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
LICENSED CONTRACTOR'S DECLARATION
Job D05CrIpI100
I hereby affirm Nat 1 sm licensed under provisions of Chapter 9 (commencing
with Sectimn 70(sO of Division 3.f this Budmas and Profcuimu Code, end my license is
in full fore..nd Effect.�906r10
TENANT IMPROVEMENT -NEW INTERIOR
License CI Lk. N
Dam j� 7/ Contranor n v L -
ARCHTTECTS DECLARATION
1 understand no, plans about housed as public rtcnrds
Licensed Poor cssintend
OWNER -BUILDER DECLARATION
1 Wreby affirm that 1 am exempt from tW COmmClo's Licenx Law for the
following rcanno. (Seed.. 703 1.5. Business and Professions Code: Any city or county
which requires a Permit to consumer. alter, improve. ocmol6h, or repair any mature
$85000
prior m iL411{Uanee. also requires lire applicant for such perllit to Blc a Signed statement
he is licensed m tW of On Comtracmr'sicense Law (Chapter 9
Sq. Ft. Floor Area
Valuation
that pirstanl provisions
(commencing with Session 7o00) of Division 3 of the Business and Professions Cook) or
that Im its eumpt tMa.from and Ne basis for the alleged eumptim. Any violation of
FN WdMYer u u
Occupancy Type
Section 7031.5 by any applicant for a permit subjccu the applicant in a civil penalty of
not mom than five handled dollars ($500).
0 1, an; owner of the property. or my emPloy,. with wag, ss thew sot. wmpewdon,
Required Inspections
will do is work. and the structure is not intended or offered for sae (Sec. 70/4, Busimas
and Pmreaions Code The Contractors License Taw does not apply m an owner of
property who builds or impmvu thereon,and whodasauch work hirmelforthmugh his
Own employees. provided that uch improvements are not intended oroQe al forsale. If.
however. Ne Wilding or improvement is sold within mss year.(cmnpletion, doe owner.
Wilder will have the burden of proving that he did Out build or improve for purpose of
sate.).
0 1. as Owner of the property, am ,elusively contracting with licensed comractms m
construct ds project (See. 7044. Business and Professions Code:) The Conuacmr's U
cense Taw does not apply m an owner of pmpany who Wilds or improv, thereon, and
r�
who contracts for such projects with a conuacmr(s) licensed purwam to the Canuanor's
Taw.
❑lore exempt under See .BAPCfor Nu reason
E] Item
O
Danner Data
/
WORKERS COMPENSATION DECLARATION
1 hereby, affirm under penalty of perjury One of the following deckaratimrs
1 Acre and will maintain a Cer ifam of Consent m sel6insum far Worker's Compel.
anion, as provided fm by Section 3700 of the Labor Code. for Ne performance of the
work for which this permit is issued.
0 I have and will maintain Worker's Compensation Invasion, ss required by Section
37M of the labor Code. for Ne pmfomancc of the work for which this permit is broad.
My Worksg xcompensaakm Il'nauraven carrier and Polity mer art:
Carrier. I V-EsA i L;lLf. Policy Nu.�2 -7 2-!�_g /1
Jj S
CERTIFICATE OF EXEMMON FROM WORKERS'
COMPENSATION INSURANCE
,
(TTuaction need not b, completed if the pcmit is Favors, hundred dollars (SIM)
r
.r loss)
T carufy that in Ne perfooranee of tW work for which this Permit is Laacd. I shalt not
employ any person in any moreover sou b become subjen to the Workers' Compenvti.n
Laws of Califoroia. Das
Applicant
NOTICE TO APPLICANT: If. after making this Cedirlcam of Exculpation, you should
become subject in the Workers Compensation provisiom of me labor Code you met
'
forthwith comply with each provisions or this Permit shall W deemed revoked.
I
i CONSTRUCTION LENDING AGENCY
Ihereby afore that th.m is a construction lending agency for Ne Performance of
' Ne work fur which this pemia Is Wood (Sec. 3097, Civ. C.)
Undoes Namc
Lender Address
I I cenify Nat 1 have read As application and sus that Ne above infomatiun is
comet. 1 agree to comply with all city and county oNinanen and fuse laws minting to
building construction, and hemby amhorim representatives of Nis city no enter upon the
almvoulemiunea prorcn,for inspection iturrowhich
(We).glee to awe, indemnify and kezp harmless tW City .f Cupertino ag.mr,
m.
j cast may in any way accrue against said City
incoiti,.ju eofM.crauindofpercawhtch
A conscq Of art AND
NT
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON -POINT
UNDERSTANDS WILL
Issued by: Date
SOURCE REGULATION4.
Re -roofs
signat�rAppli,ntconuanor caw
HAZARDOUS MATERIALS DISCLOSURE
Type of Roof
Will On applicant or future Wilding Occupant store orhandle imminent material
as dello l by the Cupertino Municipal C.4, Chapter 9.11. and the Health and Safety
Cole. Semi.. 15531(.)7 -
❑ Y,
All roofs shall be inspected prior to any roofing material being installed.
Wilt thea applicant Wilding =upon( use equipment
PP B p q
If a roof is.installed without first obtainingan inspection, I agree to remove
P
ilQulordevise.which
it huraN.us air conuminanu ss tc0ned by Ne Bay Area Air Quality ManagCourt
all new materials for inspection.
Dutdm?
0r'es �Ru
1 have over the herardms mamrialseequimmenu under Chapter6.95 Edition Cairo.
ma HesIthg: Safmy Ccdc. Sections 25505.25533 an,125534. 1 understand thaddre Wilding
Cocanot currently have a mount.at it 4 my responsibility noddy the occupant or the
m
thprig
require sen whi must Ee rpet m itsuvmc of d Ccnifieam of
Signature of Applicant Date
_rapapc r
/jLJ/srl9
All roof coverings to be Class "B" or better
Owner orsutho rxtagent D