01080009 OF
CIBU,LD NG Dr ISIONNOPERMIT CONTRACTOR INFORMATION:
BUILDING ADDRESS: PERMIT NO.
20300 ^`P�TC—Y-C—AIS CRCC—k 0i110 CONSTRUCTIVE 13UILDING SV(,', INCO1080009
OWNER'S NAME: APPLICATION SUB DATE
Mkk CUPERTINO CITY CENTER ASSOCIAr 3937 39TH AVE 08/02/2001
PHONE: SANITARY NO. CONTROL NO.
(510) 531-1175
O e Z
ARCHITECT(ENGINEERBUILDING PERMIT INFO
mO
BLDG ELECT PLUMB MECH
z .i LICENSED CONTRACTOR'S DECLARATION Job Description
O Z_ 1 hereby 0)of that l ton licenced sines pod Professions
of Chapter 9lcommecense
p_Fy wiNSecaon]00o)ofDivision Jofthe Business andProfessionsCad Q�nyu<en:< DEMO OF (E) INTERIOR PARTITION$ .
<yf� is in full ionic and eQRl. ZZJ '7V
m < Litmus Claes tae.n f
3 O Dam Contmcwr
A ITEC-1 DECLAR
a O,g 1 undemmoJ my plans shall he used as paidio
rt o
wpO Littnsed Professional `
z OWNER-BUILDER DECLARATION
a�L"' 1 hereby affirms that I am exempt from the Contractor's License Law for the
H
C i< following mason.(Section]OJ 1.5, t,after and improve.
de i demolish,
Cale:Any tiny or county $15000
Z x❑ which requirts a pcwil to contract,alms,improve,demolish,or repair any swaurt
a�=-..priori t I. monies' m 'III ill hl t 11 'b d,tmmcm,
rodim sh t I...... r t.. `Ialuation
(emus r ng with SectionJ")ofDivsr Jot the Bashi dprofession;Carry G d 36bT0 .. 8ea y -: ,I;)
or that he is eiempl therefrom and the basis for the alleged exemption.Any violation
of Section 7031.5 by myapplicamfor a pernil subjects theapplicem m a civil penally ppppb�7
of not mom than five hundred donars 1$500), NO ASS I�R�ED INSPECT ON
Occupancy Type
❑1,as owner of the property,or my employees with wages as their sale rompea.usumn,
will do the work,-and the stmCmre Is non Intended or Offered for sale(Sce.]BYt.
Business and Professions title:The Contractor's License Law does not apply to an Required Inspections' •)'•'
r of property Who builds or improv..thereon,and who does such work himself
of through his own employees.provided that such improvements art not intended or -
offered foC%alc.If-however.the bu ld ng or improvement is sold-within one year of
coripletion,the nerbulder is ill have the burden f proving that he did not Fuld or
improve for purpasom of sale)
❑L as owner of the property exclusivelycontracting with emuuots m
construct the project(sec.] u,Business and professions Cade)The Cmmraclors t ..
L dens Law d«s non apply roan owner th p perry h build or improves tt to be
and who rs License
for such projcc¢xinh c w 1 rt).liccnsrd Pursuant to the
C rmcmrsLccnse Law \
❑1 am excmpl under Sec. s _ B&P C for This an
Oester Date
WORKER'S COMPENSATION DECLARATION
I hereby affirm under penalty of perjury one of the following declarations:
❑ 1 have and will maintain o Certificateof Consent to self-insure for Worker's
Compenarim, as provided for by Section 3700 of the Libor Coda for the
Performance of the work for,which this pemlit is Issued.
❑1 have and will maintain Worker's Compensatihn Insurance,as o:gmred by Section
TIIN)mflhe Labor Cale,for the performance of the work far which this permit is
issued.My Workcr'x Compen lion l number arc: —
Carrier: � E I ICV 77Pah(M No.: / 'KERS r O a•f By ..I,c.. av {'. •: ♦' n a,.l.,t.
'r
CERTIFICATION OF EXEMPTION FROM WORKERS'I �- •s t` 1 a - { e.ti:."v l S- , ,,
,.,COYtPENSATION INSURANCE";_" ' _.._.. - __. _.
( i .. _
This staton wed riot M compleicd if the permit ns fur one hundred dollen .s j - "L f .
131001 or lcssJ ,
1<ertifY than in be performance of the weak fur which this permit is isomsi,I t;
shall non employ any person in any mariner so as to become subject to the Workers
Compensation Laws of
Californiaat omt
Date
p ,.
NOTICETO
APPLICANT.It.after making this Cenifica¢of Excurnmil:you should
become subject b)the Wormes Compensation provisions of the Labii Code,you must
Q forthwith comply with.such Provisions m this fermi,shall h,deemed revoked.
._ _ ..... _ _ _ .. _.. _ _._ _. _.. .. .. J .
z'Vi ^1 ° 'CONSTRUCTION LENDING AGENCY -
F"' I hereby affirm that there is a conamction lending agency for the perfonnanceof the "
Cf, 'L Lender'work for which this permit is issued(Sec.309].Civ.C.)i Name.. ..._ .. _ ... ._ ,�..... . -.__ _ ... ... ._ .._. .. _ . ..
D Z Lender's Address
C.1 1 certify that l have read this application and nae that the above information is
WE.. correct I agree to comply wish all city and county ordinances and state laws relating
Oi(_1 to buildinganstrvcuon.and hereby authorize represenmtives of this cityno enter upon
�••-W the nbgvcmennimed property for inspection purposes.
.. E•y,p„ (Wc)agree visas,indemnify and keep harmless the City of Cupertino against
U0 liabilities,judgments,tvns and expenses which inay in any way sortie against aid
J z Cily inconsequence of the grinning of this permit.
^ AYPL A�TGULTRSTANDr ANDWILL COMPLY WITH ALL NON-POB Issued by: DBte
3 no'Vft pl aMCmttractor . ' ',Dam Re-roofs —
't e pa OSURE ". I
pp g p or handle hazvdrwsmamnal Type ofRoof
- - - - -
HAZARDOUS hIATERIALS DISCL
I thea applicant or fumrt building occupant store
as defined b the Cupertino Municipal Cade.Clarifier 9.12,and the Health and Safety,
Gide O<Ycs 255J1(rU, l,.❑No' t .r .' . . • . . z,_' s, . s Is ,
l
. .. ,_ _. ..All.roofs shall be�inspected prior to any roofing material bei ngJnstalled. . ..
Wdlmeopprcavterfmnrcbailding.,.,actuse equlpmentordsvhsswhlch'' If a roof is installed without first obtaining an inspection'•'I agree to remove
emir himbloas air mnuminants as defined by the Buy Arca Art Quality Management
Diatricc- all new materials for inspection. Applicant understands and will comply with
- -ores [I No all non-point source regulations. 1',.
I have head the hazardous materials requirements under Chapter 6.95 of the
California Health&Safny Code Secuons]5505.155JJ arainstJ.l underimulthia _ --
,if the building docs not curmly have a whim,that it Is my responsibility to notify the i
occupant of the requirements which must IK met prior to issuance of a Certificate of
°""p' - y•g, Signature of Applicant _ _ Date
•o a mnri< eel . . Date All roof coverings to be Class "B" or better
OFFICE .