04050164 CITY OF CUPERTINO (�as 'tTa. ('�a`(j�3 ry��a"T A� ��°Tara'
BUILDING DIVISION PERMIT CONIT RrAl�'R^; MAvg, ""
BUILDING ADDRESS: JSJ ELECTRIAL DISPLAY PERMIINO.O4050164
19900
OWNER'S NAME: PERMIT ISSUE DAIS
DREXEL HERITAGE FRUNATURE 459 INDUST
E: SANITARY NO. CONTROL NO.
7077475595
ARCHITECT/ENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMBMECH
a 0 0 0
Y 0 0 LICENSED CONTRACTOR'S DECLARATION
F I h 7 serum that 1 em licensed under pmviai0na of Chapxr Y(rnmiemaing
with Sectimon]QM)of Division of LW BusinesSIGNs end Pr sir C andm licenx is
y}arc
ntun race p�n
p Z Llcenu Ctts>ti( Lk.M
Qat DSC1
e R 1 crs DEcuaA 7on�
t ��HII
Y
In srJ�l c uygTar�r
J WyU
3 C Lice d P cosi al
g at I ma aUILOER DECLARATION a��V�I�
4 F rah no than 11. exempt from the Cnnuecloo e:Any c Law for the V
mg reason.(Smuou ID3 s 5,Bualness and Professions Code:Any tiny or countyou
which its issuance,s aim re cnnswe,alms nt for
demolish,or repair any awdmp
_ y thior s hest ensedpurse requires the applicant of for Contrach ctor's
micensrite ae ned Law then he is licensed pursuenlmthe previsions ser the Comrumh Llcenu Taw(Chapmr9 SLI.Ft.FIOOC Area Valuation
xG Commencing with Section 7000)of Division 3 of the Busimaa and Professions Code)or -
that he u exempt therefrom and the beak for the alleged exemption.Any violation of
Section 7031,5 by any applicant for a permlt subjects the applicant Ir a civil penalty of , Occupancy Type
not mots than five hundred dallan($500).
❑I,a a owner ofthe property,or my employees with wages as loos sole compensation,
will do the work.and thewracture lsnotudended reoffered fonala(See 7046,Business Re
and Professions;Code:The Conamom's License Law docs ret apply k an ownqui
of 9
Fe NALED
property who Wildsmimproves Nemon,andwhodoesamhworkhimselforthrough his
own employees.provided that such improvements art not intended coffered for side.If,
however.the building or improvement is old within one year of completion.the owner.
bonder will haw the bNm
uof proving that he did non Wu build or Improve roe puryoof
q I I I1 31 /nI lg
eska.
1,as owner of the property,em exclusively property
who Wi with licensed convectors k N constnmt the project(Sec.7044,Busineu end Pro(esaions Code:)The Convukr's W- � FD
cense Law dopa not apply men owner es property who Wildsor deimprove sumer end.
whocwho mnlmck for such projects with aeontruta(q licensed personal m the ConvuloYe BTW
Licansetaw.
❑I am exempt untler Sec. .B,kP C for this moon
Owner Data
WORKER'S COMPENSATION DECLARATION
I hereby aftne under penally of perjury am of the following declan0ans: 1111 16 2004
1 M1mex and will maintain aCcAOcam of Consent o self-intim for Worker's Compen-
workf for
for by Stenon 3]011 of Ne Labor Code,far the performance of the BUILDING
work far which Nie pertnin is issued.
❑i have and will maintain Worker's CompemNon Insurance.re acquired by Secure
3700 aide labor Code,for Ne performance orthe work for which this permit ie issued.
My Waken o Iqlagrance carrier and Policy nu r :—w6 f/„�i
Cartier. Polity Nae _f�-L
CERTIFICATED TIONI NFRA WORKERS'
COMPENSATION INSURANCE
( hissection need not hecompleted ifthe pmarit is furore hundmddolkrs(3100)
nr leas.)
1 certify that in the performance of the work for which the permit is issued,I shall not
employ any person in any manner an as in bacomc subject to the Workers Compensation ,
Laws mfCalifornia.Date
Applicant
NOTICE TO APPLICANT:If.a00t making this Goodrum of Exemption,you should
became Subject 0 Ne Worker's ComMmistlon provisions of the Labor Code,you must
�0 forthwith comply with such provisions or this permluhail W deemed revoked.
'Z CONSTRUCTION LENDING AGENCY
[-i I herchy a from than Nem its comuuetinn lending agency far the perfurromea of
all 7 Bre work for which this permit is issued site.3097,Civ.C.)
aQ Lender's None
= z Lender's Addmu
U Q 1 certify Nan I have read this application and some than the be.information is
[a. F correct.I agree be comply with ell city and county ordinance;and sum laws relating an
0 building connotation,and hereby authorize repreacnuuves of Nis city to amerupm the
fad eWvs-manuoned pmpaly for inspection purposes.
(We)same to cove,indemnify and kith harmless Rte City of,agent against
fn liabilities,judgments,coati andmnify andwhich epmayin lsnywayty of Curie
colo City
U Z in consequence of the It of this permit.
APP U ST AND WILL COMPLY WITH ALL NON-POINT Issued by: Date
RCE
S � Re-roofs
Sign a App V ntnctor Data
ARDOUS MATERIALS DISCLOSURE Type of Roof
ill the rant.,auto
building occupant aim or handle ha'rardous manual
defined by the Cupertino Municipal Code.Chapter 9.12.and the Health and Safety
Code.Secuen zssu(a)l All roofs shall be inspected prior to any roofing material being installed.
❑Yes No
Will Nc applicem o fuwm building occupantesu cyuipmcnl or devices which If a roof is installed without first obtaining an inspection,Inagree to remove
tie,? nus air conumymdefined by Ne Bay Arca Air Quality Management all new materials for inspection.
D,ha
❑Yes I have reed the ovaterialsmquiremenu under .Chapmr6.95oftheCalifor-
riell thASafcty2-"'
S,25533and25534.1undcrsundthatifthe building
docs non o n s apo sihiliny m notify the occupant of the
recall ents whi as acemrcau ar. ignature of Applicant Date
owns rr nl -A I e Dam All roof coverings to be Class "B"or better