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CITY OF CUPERTINO''�-"�^
BUILDING DIVISION PERMIT
c-ONTRACT,OR4INFOit RATION
BUILDING ADDRESS: _
PACIFIC GENERAL CONSTRUCTI
MMRN004060206
19770 STEVENS CREEK BLY171
OWNER'S NAME:
PERMIT ISSUE DATE
EVERSHINE VI L.P.
E:
SANITARY NO. CONTROL NO,
510)713-9343
ARCHITECT/ENGINEER:
BUILDING PERMIT INFO
'
BLDG ELECT PLUMB MECH
LICENSED CONIRACfOR'S DECLARATION
Job Description
I bemby affirm that 1 am licensed under provisions of Chapter 9 (commencing
iN Section 70(18) of Division 3 of So Business soul Profasions Cade. and my license is
famd effect.
ind0rc.
DEFERRED ELECT. /MECH
Utma Class Lis. p
Dam Contractor
ORIG. #03100011 (SHELL ONLY)
ARCHITECTS DECLARATION
1 understand my plans shall be used a public meords
v
Licensed Professional
OWNER -BUILDER DECLARATION
1 hereby elErm has I me u.mpl from the Comnnm's License Law or the
following ...a. (Sectum 703 1.5, Business and Professions Conic Any city of county
which require a Permit to construct, altar, improve, demolish. or repair any structure
prior to its issuance. also requires Ilk, applicant for such Permit a rile a sigocd aumment
that he is licensed pursuant m the Provisions of the Cmustelm's Licence Law (Chapter 9
Sq. Ft. Floor Area
Va" 1000
(commencing with Section VOW) of Division 3 of the Business and Professions Code) or
has ha Is exempt therefrom and the basis for the alleged eanmption. Any Antedon of
APN Number
Occupancy Type
SeNom 7031.5 by arty applicant for a permit abjecu Ne applicant to a civil Penally of
not mom Nan Ove hundred dollars (5500).
36906009.00
Gl,uawmerofNpropeny,mmymploymwithmmuduirmlemmpemssdon,
Required Inspections
will do the work and the,bucture is not inumded moQered boned. (Sec. 7004, Business
and Profession, cox: The Camuecmes License Law dao mut apply m an awns, of
property who builds or improves Nerme. and who doessuch wmk himalf or through his
own employees, provided that such improvemenu arc nolintended oronered (mule. It.
however, the building or Improvement is sold within one year of completion, the owner -
builder will have the burden of proving that IN did not build or improve for purpose of
u1..).
&.Up/ 1, a owner of the proton, am exclusively contracting with liansed tom ssum, to
tmcl the project (Sec. 70ad, Business and Pmfessiou Code:) rho Conuaemes Li -
cease law docs not apply m an owner of Property who builds or improv demon, ad.
who contracts for such projects with a contractor(s) licensed pumanl to use Convactors
License Lew.
❑ 11am a-mappt u�no., S.S.B A P C�foorr this mason
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O�paL. Y /0'gW (� f�C. ,. Dau W 4 ?j
WORKER'S COMPENSATION DECLARATION
1 hereby aRorty m under perof perjury ON of Ne following declaralioa:
-
have and will maintain a Certificate of Co..[m aelf-lau a for Wmkera Cheapen -
n, as provided for by Section 3700 of the Labor Cods, for the performance of the
work for which Nb permit is issued.
❑ 1 have and will maintain Worker's Compensation Insurance, a required by Section
371 of the Labor Cox, for the performance of the work for which this Permit is issued.
-
My Workers Campeuadan I ..... .not. and Polity number m:
Cartier. Polity No.:
CERTIFICATE OF EXEMP71ON FROM WORKERS'
COMPENSATION INSURANCE
(This Nada. need not M camplcud If the permit is Rumm hundred dnllm (510r)
or lues)
1 certify but in ON perfmmem. of Ne work for which this Permit is issued, l dull not
employ any person In any meaner so a m become subject be dC Workers Gompeonsa k m
Laws of California. Dam
Applicant
NOTICE TO APPLICANT: If, after making this Certificate of Exemption, you should
became subject m the Worker's Compcnation provisions of the labor Code. you mum
forthwith comply with such provisions or this permit shall M deemed revoked.
CONSTRUCTION LENDING AGENCY
I hereby affirm that then is a construction lending agency for the Performance of
'
Ne work for which this permit H issued (Sus. 3097. Co. C.)
Leaders Nmc
Iamders Address
I ttnie that I have rod this W un is
application and ,tate Net the shoee ws
eel
comply with all city and county anttnmcu and sou lawn refiling
cored I agree city and
e
building construction and hereby authorise representatives of Ni, city to tour upon be
c
aM1ovr purposes,
ertysaw, for emnify
an
(We) agree no ha
(We) agree to uve, indemnify and seep harmless w City o Cupertino ted try
Iiabili0u,judgments,cuts eadtxpea.. which may lneayway aortae a8un,tsaid City
ps
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in<auegmnce of the greadng of this permh,
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON -POINT
Issued by: Dat
SOURCE RE 'IJ a
�3�
�( � d 1)�
Re -roofs
Signature ab pelican 1R Data
HAZARDOUS MATERIALS DISCLOSURE
HAZARDOUS
Type of Roof
WIII or (muni building occupant store or handle ha�oua material
u de. y t e Cupertino
by the Cupertino Muninpel Code. Chapter 9.13, and the Ha1N and Sa(cry
Sed
Code. Section zs532(07
All roofs shall be inspected prior to any roofing material being installed.
❑res KN.
If a roof is installed without first obtaining an inspection, I agree to remove
a Will to applicant or future building=upon, use equipment or devices which
�arardnu air contaminants as defined by the Bey Area Air Quality Management
all new materials for inspection.
istrin?
0Ycs Og NO
1 hove mad IN ha'raNm,maurialsmquircmcnts unser ChaPur6.95 of the Calif.,
me Head" SafctyCax, Sections 255U5.25533 am125534.1 undenund Nmibthc building
does act currently have a m arL that it is my rapouihility m notify IN OceuPant of ba
myuimmcnss whit t�9�pd priorm lsfuanaof.corurcauaf Occp cy.
7 23
Signature of Applicant Date
r,�Lf B �2 [� �i
All roof coverings to be Class "B" or better
Owner or amhmized agent Dam