04040114 CITY OF CUPERTINO
BUILDING DIVISION PERMIT CON`IBACTOR INFORMATION f
BUILDING ADDRESS: PERMIT No0 4 0 4 0114
RSNAME PERMIT ISSUE DATE
SYMANTEC FITNESS 2004
NE: - SANITARY N0, CONTROL NO.
ARCHITECT/ENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
0 F__7
0 0
too LICENSED CONTRACTOR'S DECLARATION
hereby affirm that 1 am lianscd unO'Pon
v ons of chapter v(commencing Job Description
w with Sen as] s)of wision3oftrc laad.�J�ssium, d and my license is q �k as t-
in roll fore err t. G7l/�Y ,ky'w �G 2 NEW EXHAUST FANS FIF-4A•7 IYLIaYE
j�? Llccnsc p
;� Date ter CONTRACTOR: ACCO
RCHITECPS E ATION MAY 5 - 2004
i adersta s I W used a lic r cards
gw;0y Licensed Pn+fcssi al
g OW NER ILDER DECLARATION
IF 1 hereby infirm that I am a mpt from the Contractor's License Low for the BUILDING
i p O following mosnn.(Secdon 703 L5,Business and Professions Code:Any city nr county
m which requires a permit to construct,alter,improve,demolish,or repair any structure
_Ey pdo,toies issuunce,also mywres hripraeant for such permit to rile a signed statement
££rep that he is licensed pursuantto the provisions Ofthe Contractor'License Law(Chapter 9 Sq. Ft.Floor Area Valua*5g1000
yt- (commencing with Section 7000)of Division 3 of the Business and Professions Code)or
y,� Net he is exempt therefrom and me basis for Ne alleged exemption.Any violation of
Section]031.5 by any applicant for a permit subjects the applicant o a civil Penalty of APN Number OccupancyT e
not more than rive hundred dollars(5500). YP
E]1.m owner ofthe property,or my employees with wages as docirine compensation, 36901019 . 00
will do the work,and the structure is not intended or offered for sale(Sec.]044,Business
and Professions Code:The Conwctnr's License Law docs nal apply to as..at of Required Inspections
property who builds or improves thereon,and who doessuch work himself or thmugh his -
own employees,provided that such improvements are not intended or offered for sale.If,
however,the building or improvement is sold within One year or completion,me Owner-
holder
wnerholder will bare the burden of proving that he did not Wild Or improve for purpose of
sale.).
❑1,as owner of to property,am exclusively convecting wish licensed contractors to
consruct the project(Sec.7044,Business and Professions Cade:)The Contractor's Li
came Law does not apply to an owner of property who Wiids or improves thereon,and
who contracts for such projects with a emileactor(s)licensed Pursuant o the Contractor's
License taw.
❑I am exempt under Sec. ,B&P C for this reason
Date
WORKER'S COMPENSATION DECLARATION
I hereby Orion under penalty of Perjury one of the following declarations:
❑I have and will maintain a Certificate of Consent to sel binsure for Worker'sCompen-
stalion,as provided for by Section 37W of the labor Code,for me performance of the
work for which this permit is issued.
I have and will maintain Worker's Compensation Insurance,as required by Section
37W of the Labor Code,for he performance Of she work for which mix Permit is issued.
My Wmlwex Cnyfq.1en�'aat, nInInssuur�ance cagier and Policy number art:
Ef IFTCATE OF EKEMPf1 oM WORKERS'
COMPENSATION INSURANCE
(This section need not W completed if the permit is for one hundred dollars($100)
or less.)
1 certify that in the performance of the work for which this permit is issued.I shall not
employ any person in any manner set as to heeman subject to the Workma Compensation
Lew.of California.Data
Applicant
NOTICE TO APPLICANT:If,after making this COrdfic'ale of Exemption,you should
become subject to the Worker's Compensation provisions of the Labor Calc,you must
.JO forthwilh comply with such provisions or this Permit shall be deemed revoked.
Z"' CONSTRUCTION LENDING AGENCY
tom. Ihereh affirm that mea is a construction leaden itenc In the lumme,of
F r s .) r r Per r
E
n Le work for which this permit is issued(Sec.3(197,Civ.CJ
Q Lender's Name
,a z LcnderE Address
U Q 1 camly met 1 have mad his application end state that the above information is
W f-r correct.I agree to comply with all city and county ordinances and stale laws rclming h
CU
building contraction,and hereby authorioe representatives of this city to enter upon the /
oned
ahconsequenceo the granting
inspection Purposes.
(We)agree IO save,indemnify and keep harmless the City of CuPcnino against
tiN liebilities,Judgmcnts,costa sad c.pcnacs which may in any way accmc against said City
U ,'� APPLICANTc of DERST of this permit.
'-" APPLICANT UNDERSTANDS AND WILL COMPLY WIT ALL NPOINT Issued by: Dale
50 CE REGULATIONS.
11�AA 'i Re-roofs
ignalurc of APPliceHAZAROO ATERIALS DISCLOSURE Detc Type of Roof
Will she applicant or future b ding occupant store or handle hazardous material
as defined by the Caperton Man pal Code,Chapter 9.12,and the Health and Safety
code, 0 es xss3xa)] All roofs shall be inspected prior to any roofing material being installed.
' ❑Yes No
Will the applicant or furor vilding Occupant use equipment or devices which If a roof is installed without first obtaining an inspection,I agree to remove
cmil haamdous air comma nm JefncJ by the Bay Arca Air Quality Management all new materials for inspection.
District]
❑Yes Nn
Ihave read me hara n ooterials requirements tomer Chapter 6.95 of the Califmr
me Health&Safety Code,Sections 8505,15533 and 8534.1 and rsund that if the,building
does not currently have a tenant,that it is my responsihilay m n+dly the cuPmt of the
rcyuimn nts?sJ chrm Wmet prior to issuance nfa Ccniri t of Occu ancy.
Signature of Applicant Date
Owner or authmr ed agent Date All roof coverings to be Class"B"or better