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CITY OFCUPERTINO
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BUILDI NG DIVISION PERMITC�NTRAGT,:OR.I�„NOTiMA'T_IN
BUILDING ADDRESS:
PACIFIC GENERAL CONSTRUCTI
MM7NO-05110041
19,638 STEVENS CRK BLVD
.RS NAME:
PERMIT ISSUE DATE
CUPERTINO FINANCE (#270)
43050 CHRISTY 5T
11/0R/200S
E:
SANITARY NO, CONTROL NO.
(510)824-0490
ITECffENGINEER:
BUILDING PERMrr INFO
BLDG ELECT PLUMB MECH
LICENSED CONTRACTOR DECLARATION
lined of Chapter 9 (commencing
IL ' •p 74 r
Job Desenptlon i
I Wreby affirm that I am muter provisions
with Section 7IX1U)af 'viton]af the Businev E HafesgppS. Carica n�ylkcnsces
py+
V/10
in fall=.aa /Y
ucema Cl Lied
Dam ComraaCL
TI --OFFICE SPACE ' ;'
/
r't%I .,v„�,•
DECIA ATION
Y
Y
= used
I 1 ursshall W ntleunJ my plans shall uxJ as public esc.rds
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Licensed Prefasional
OWNER -BUILDER DECLARATION
I hereby alLrm that 1 am exempt from Ne Contractors License Law for the
I following mm e. (Section 7101.5, Business and P.I.mm Cale: Any city or county
which esquires a petal m Co.I, alcor, improve, demolish. m repair my suuetum
-
j.( �,� 5 9 2 Cj O
! prior m is in...alw requires the applicant for such permit to file a signed autemcm
the Contractor's Liccme Law (Chapter 9
Sq. Ft. Floor Area
'Valuation
that bu is liccmed prmant in the pmvisiom of
(commencing with Sargon 70M) of Divides 3 of tW Busiacs and Proreai.m Cade) or
S that he s exempt thcmfmm and the bass fm the alleged exmption. Any violation of
Occupancy Type
Section 7031.5 by say applicant for a pemhit subjects the applicant m .civil penalty of
amt more than fiw hundred dollars (SSW).
❑ I.as awdds of tie property,mmy moploym with wagmutlm'v sale campewtion,
e ns
Required Inspections
will do the wo& and theswcture Is not mmadcd moRered Ingots (Sec. 70". Business
d Profession Cods, The Contractors Liceme Law Adds got apply m an owner of
anns
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property who builds or improves Neeson, and who does such work himself or drought his
imps am rat intWN mpRarM fm ale lr,
awm employem, provi.r
old wits
im,msach
vinshaltwithinarcyearammpkdogtheowner-
in haw tan Wndan o(pmving that k tlitl not Wild m improve for purpose of
Wilder will
.In).
arc.).
0 1. as owner a the property, am mcluumly contracting with ncensea ma .fan W
construct rbu projem (Sec. 7044, Bminass and ProPsdms Code:) The Co.oacmrs Li -
came raw dna a o apply m m. of propmty'wW builds., improves thertmh, and.
who contracts for such projects with a conoacmr(s) licensed pmsmmt m the Comresses
Liceme taw.
0 lammempiunder See ,Bk PCforthiaroaon
Dam
WORKERS COMPENSATION DECLARATION
1 hereby affirm under penalty of perjury ane of the fallowing declarations:
fl
w and will mountain a Con-fifieme of Consent in self -Images for Workers C'ampen.
niton. as provided fm by Section 37W of the Labor Code. for the performmxe or to
work far which Ws permit is shed.
0 1 have and will maintain Workers Compcnaton Inman¢. m required by Sccuom
37Mo(the Labor Code. for the performance of one wank Tar which this permit is issued.
'
My Wat�ter.,s �CCoom�v,gva.�regation huurana artier and Polity n m er t
�lfl+Ll/_
Cam.1-57Ar rL Policy No.:
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
Crhsxctiom recd not W complcmd if Um permit is foronc hundred donna (SIM)
gr leu)
1 cert(v that in the pcafora aa:e of the work for which this permit is Lnued, I dull not
employ any person in my manner ha u on become object o the Wortrn' Compematan
Laws of Califer ia. Date
Applicator
NOTICE TO APPLICANT. IL after making this CcNOam of Exemption, year sW.W
Wemne subject to the WorkCra CompenLAmh pre ielom of the LJWr Cade, you a"
' forthwith comply with such prosvioro or this permit shsll bu deemed hawkad.
j CONSrRUCTIONLENDING AGENCY
for the performarce.(
1 Wreby aRam this there sacd(Sce.
30lending.)
the doh for which this pemtit s exceed (Sec. 309], Civ, CI
I Lenders Nam.
Lenders Attracts
I certify that I haw rood this .,Iic ion and sate than We abuse information s
' aara= I agree in comply with all city and county ordirunca and sate laws relating W
Wilding construction. and hereby mthorire represenuuscs of ths city in enterupnm tW
ilgw-memtidged pmpeny (an inspection es -
(Ws,) agree m nw, indemnify and keep hamtas the City of Cupertino against
i liabilium.judgmenu.emu and expenses which may In my way iccroe agaimtsud City
may
hat eomequa of gent gofthNQ WI
' AP ICA U S AN13.WIL1. COAL' WITH ALL NON -P Nr
U ECU Q�07(.i KAIs( 771st/
Issued b Date
y
Re -roofs
Type of Roof
St ma( ppb
HAZARDOUS MATERIAISDISCLOSURE
Will the appliamt.r Ignore Wilding aavpmt ams, arharhNc haraNaus maxriat
as de0ned by the Cupeniw Municipal Cade. Chapter 9.13, aM tic Health and Safety
oblise.Sc ye 25532(0)7
❑Y.a a
All roofs shall be inspected prior to an roofing material beim
P P Y g g installed.
EWill thc applicant or furore building accapant use equipment or devim which
If a roof is installed without first obtaining an inspection, I agree to remove
, booth.. air canum counts as tic red by the Bay Area Air Quality Mmagemcnt
all new materials for inspection.
Diavict,
0Ya NN
Nan nuxrials requirements; under Chapter 6.95 ofthe Califor.
.isay.rhs�5t . 25533 ant 255N.1ualrrsan e Wilding
teak (th s my esapomihility b notify of dmW
Wool
tip g,imuam<araBayaa a.
!/
W.n,�d
Signature of Applicant Date
All roof coverings to be Class "B" or better
,m ..