01100025 CITYBUILDING DMSRIONNOPERMIT CONTRACTOR INFORMATION:
BUILDING ADDRESS: PERMIT NO.
19979 STEVENS CREEK BLVD 01100025
OWNER'S NAME: APPLICATION SUB DATE
VINCE GIACALONE 10/04/2001
PHONE: SANITARY NO. CONTROL NO.
O O ARCHITECDENGINEER: BUI G PERMIT INFO
toL- BLDG L PLUMB MECH
giu5 L I J L.J LI
u i LICENSED CONTRACTOR'S DECLARATION Job D cnphon
z=C I hereby affrn that 1 am Sardsed under provisions of Chapter 9 m
(comencing
rota, witin Section 7000)afoivi,xm3anhasaeiaiProRssfom.Codatndmylicense TEMP POWER.
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A a aasc Clns c O Lire.a or b—I
Data s Conman
S 3 u ARCHITE T'S DECLARATION
a sr 1 waround my Plans shall be used an public recordssr
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lE O O Li - Professional
6 OWNER-BUILDER DECLARATION
I he,
allmn that 1 am exempt from the Contractor's License Law for the
C?< allowing reason.(Section 7031.3.Business and P,vlessians Cole.Any city or county $200
E s O which requires a permit to construct.alter.improve,demolish,or repair any snocmm
nam poor to its issuance,also requiresNapplicantf par
mut putt file a.gned su¢rc
tm.
that he is 1 ceased Furs t to the provision.of the Comments' tt L u Law(Chapter 9 �j�j l�eH3 �jy Valuation
(commencing with Section 7000)of Divi: J f the Business d Professions fessions Cade) {„ �s I '.3.1 [0`?� \\
or that he A exempt therefrom tend the basis for the nlli,ad exemption.Any violation 1
of Section 70313 by any appfi¢ent for a permit subjects Ne applicant last civil penalty
of root mote man five wodrtd donari(sso0). 10 3 APN bipZ�,pr , Occupancy Type
❑Las owner of the property,or my employees with wages as their sole compensation,
will do the work.and the swemrt is not intended or offered for sale(sec.7Os4 Required Inspections
Business and Professions Cada:The Contractor's Licenw Law does not apply to an
owner of property Who wilds or improves thereon,and who does such work hinu,lf
orth,.afh his own employees,provided that such improvements art not intended or
offered for sale.If,howcvca the building or improvement is sold within one year of F�
completion,the ox'ner"builder will have the burden of proving then he did not Wild or
improve far puryoee of sale.).
mpery,am exclusively contracting withenerd m
licnBettirs no
❑Lasowncrofdhep
comwct 0,project(Sec.7W.Business and Prefeuions Cotler)The Contractor's / � -
License Law d«s not apply to an owner of property who builds or improves th icon,
and who contracts for such projects with a codurc or(s)licensed pursuant to the
Contractors License Law. 7
O l em exempt under See .B R P C farina reason t
Owner Data
WORKER'S COMPENSATION DECLARATION
I hereto affirm under penalty of perjury one of be following declarations:
O 1 have odd will maintain a Carrolton, of Conutn as s,i-irsure for Workers
Compcnsois , as provided for by Section 37W of the Labor Cade, for the
perforraaee of she work for which this permit is insured.
❑1 have and will maintain Worker's Compensation Insurance,on required by Section
3700 he LoMr Code,fm the palimm nice of one walk for which this permit in
iss y Worker's Compcnution 1micamca carrier rind Policy number are:
STwr Cap �wS:Fgr
I'd.: /Gd F.
CERTIFICATION OF EXEMPT10N FROM WORKERS'i -
COMPENSATION INSURANCE "
mo,union decd nm be completed if the permit is for one hundred dollars
ISIOff it less.)
1 certify than in the perfotmarre of the work for which this pemdt is issued,1 - - Ni .. ;.t f•L.I
shall not employ any,person in any manner so as to become subject to the workers
Compensation Laws of Califomia.Date
-Applicant .. _ - ...
NOTICE TO APPLICASEP IL aftu making this ote
Ceaifiof Exemption,you should • "
Z become mbjem ria thre WoAces Compensation provisions of the Labra Cade,you must
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forthwith comply with such provisions or this permit shall w deemed rooked. '
FZr" ^ CONSTRUCTION LENDING AGENCY
' 1 hm6i affirm Wt Here is a construction lending agency for the Performarwx
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of the work for which this permit is issued(Sec.3O97,Civ.C.) - -
(� Lender's Name
Lender's Address
agree
the 1 have read this application and store the rhe above information is
W U career I agree to comply with all shy and county ordinances and stats laws enter
upon
Q,W to idsona-mardi ueioaand
sly Or
smhtion Padpres,nmtives of this city mercer upon
ps the ewWe)agree to pmpcny for inspersion purytue.
f+ (Z) I We)agree to save.indemnify and keep harmless the City of Cupertino against
r Vi MR
itics�ladg costs and expenses Is may in any way eceme against said
V z the gmn'tg ap[nhl FSTA eGW 1PLYWI HALL NON-POINTIssuedb DateON. �`' yConwcter Date Re-roofs
ZARDOUS MATERIALS DISCLOSURE
Will the appli.t or metre wilding occupert nor,or herWk hicardoems meterind - Type of Roof
as defined by the Cupertino Municipal Cache.Ch,ner 9.12,end the Health earl Safety
Cade Section 23332(a)^
Oyes ON.,:
All roofs shall'be.inspected prior to any rooffng.material being"installed.
Will the applicant or future building occupant use equipment or devices which If a roof is installed"without first obtaining an inspection, Iagree to remove
emit hazardous air contamiwms as defined by the Bay Area Air Quality Management
Disinenall new materials for inspection. Applicant understands and will comply with
Oyes ❑Noy all non-point source regulations.' -
.'t. . .
1 have read the hazardous marerlale requirements under 4.1 ter 6.95,.of the
AEM
yhave ons23303,t itis yrespo34.1undenotifthey havcomnant Ne in is my responsibility to notify them Bn n b t pnor to issuance of a Cmificam of Signature of Applicant . Date
mmerar nathmizW.gets[ ' Data All roof coverings to be Class"B" or better
OFFICE