05050036CITY OF CUPERTINO
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`CON TRACTOWINFORMATIQN
BUILDING DIVISION PERMIT
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BUILDINGADOREss:
772 RXR3jB?;S
KEEN ON CONST. CO
PERMITNO.
GREEK B1319ED
OWNER'S NAME:
PERMIT ISSUE DATE
NE:
SANITARY C OL NO.
ARCHITEC (ENGINEER:
BUILDING PERMIT INFO
BLDG EI,ECI' PLUMB MECH
LICENSED CONTRACTOR'S DECLARATION
Job Description
o
I Mreby &farm that 1 am Hamed under Provisions of CMpmr 9 (commencing
with Section 7")or Division Sof Na Business and Proportions Cade. and my license la
'
Licfell
xmu CIandeffem. iso•
REVISION--CHG DOOR HARDWARE
NO NEW PERMIT ISSUED/ORIG. #04110039
Date Cormaccor
717SDE
ARCHITECTS DECLARATION
1 undcraund my plans Nall Ins used as public mucus
Licensed Pnlfcssional
OWNER -BUILDER DECLARATION
1 hereby affirm Nat I am exempt from the Contractor's License Law for the
following "mon, (Section 70313, Business and Professions Code: Any city or county
which nor.j. a Permit m conswct. alter, improv, demolish. or repair any suucttrc
prior m its issuance. M expires On applicant for such Permit to frit a aimed statement
he is licensed of the Comment's Limns, Law (Chapter 9
Sq. Ft. Floor Area Valuation
that pursuer, m the provisions
$0
(commencing with Section 7000) of Division 3 of the Businemm l Professions Cade) or
thouM la exempt therefrom and the basis for Um alleged exemption. Any vioiadon of
Section 7031.7 by arty applicant for a permit subjects the applicant to a civil penury of
APN Number Occupancy Type
not mom than Ove hundred dollars ($300).
'
C] 1, as owner of the property, or my employees with wage u then "to compensation,
36906009.00 �
Required InspectloTL�
will clothe wmL and On auueum is oro intended or offered for min (See. 7044, Busirwsa
and Prof.rtlon. Cod.: The Commoner Lion¢ Law does not apply m an owner of
property who builds ed improve Nereon,an lwho danauchwork himselfer through his
own employees, p such improvements are ded morteed far rola If.
ar Impevment is Bold tsd an year the oween
bowew, the buil og., improvement in ens year of comove
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for
builder will Nv the buNen approving N.I M did not build or Improv for purpose of
the i
�J
ss J.
I, a mvner of the property. am "elusively comaied.g with licensed eomactors to
a t the pmJem (Sec. 7044, Business and Professors Cade:) The Consumes LI -
come Law docs not apply in an owner of property ". builds or tmpe.Onerm. and,
who contracts for such patients with a comrs twp) licensed pursuant u the CantrammS
License law.
Ilam "emptu i [a .B,4 PCp thla aeon
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0 er -,a.
��WORKER'S COMPENSATION DECLARATION
I hereby afar" under penalty of Perjury onc cribs, fallowing decianuons:
1 ham and will maintain a CeNfrceu of Coment in salf-Imus fee WorkersCompen-
sauon, as provided for by Section 3700 of the labor Cade, for the performance of Na
work for which this permit is issued .. ..
-
❑ 1 ham and will mainWn Worker's Compensation Imunom. an required by Section
3700 of Ne Labor Code, for the performance of the work forwhich this permit is issued.
My Wmkefa camps m oor. Insurance curie and Policy number tic:
Caller: Policy No.:
CERTIFICATE OF EXEMPTION FROM WORKERS'
'
COMPENSATION INSURANCE
(Th 1saction need not M completed lithe permit is fm ane hundred dollars (S I04)
m lees.)
1 cenify Nat in the performance of tiro work (or which Nis Permh la Issued. I Nett nm
employ any Perla n my mannc• soAs mAee;m aubjttt to tM Worked' Compmeation
0
Lawn of Cali(mrdL _TS/T� O S
f0
NOTICEon. Mould
OTIC j9.c' 1 Wattle, sficr N4 Cisinsofcion of
dTop
become lab" Cade, you most
the Workers Compensation patvisioas of Later
become stomp
'
forthwith comply with such provisions or Nie permiuhdl 4 deemed reeked.
y s orthis de
CONSTRUCTION LENDING AGENCY
1 herby a01rm Nat Nov In a construction lending agency for use performastm of
Ne work far which mile permit is issued (See. 3097. Civ. C.)
'
Leader's Nam.
-
Lender'sAddm.
I certify Nn I ham read this application and sate Nat the maim infmmadon is
cortex I agree m comply with all city and county cNirunces and sum laws misting in
building construction. and hereby someone representatives of this city to cnur true the
and" -mentioned property fm inspection purposes
(We) agree u save. Indemnify and keep harmless the City of Cupertino mount
liabilities judgments. tomo and expenses which may in my my acmue against said city
e tnrtno& of this Permit.
APPLICANE0.5TANDS AND WILL COMPLY W111TTTTTT��� ALL tttjjj000N-POINT
in camequc#ATIONS.
Issued by: Date
SOC E R / ✓
_j / / `
Re -roofs
Type of Roof
Signup A teant/Contrmur f Dam
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future building occupant more or handle hanardous material
as dcOned by the Cottonton Municipal Cade, Chapter 9.12, and site Health and Safety
de, section 23332(a)7
❑Yr, No
All roofs shall be inspected prior to any roofing material being installed.
I
If a roof is installed without first obtaining an inspection, I agree to remove
Will the applicant fptpe building occupant use equipment m devices which
it In ardnas it conuminm s u &food by the Bay Area Air Quality Management
all new materials for Inspection.
trio?
❑Yr, A71Nu
I ham mad the heardoas materiebrequimmenra underCNpter6.9l Orme Califor-
Intnioliffic7nmala,cral
0 I uodeeund muifNc building
no,Cade.Scalise.1it 1.25SJJaP.ibil4.1
a not cu own temna thar . my eaponsiIX
m notify Nc000yyyxis t of Ne
iren,� nmuu ars met priorwissumee ora Ccnincate of OccW�
Signature Of ApplicantDate
.01
All roof coverings to be Class "B" or better
am