05010110N
CITY OF CUPERTINO
'
BUILDING DIVISION PERMIT
�;CUNTRA,TORTNURMAT a
BUILDINOADDRESS:
TRITON CONSTRUCTION CO.
"""05010110
OWNER'S NAME:
PERMIT ISSUE DATE
SYMANT
ONE:
SANITARY NO. CONTROL NO.
NI7ECfA3NGINEER:
BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
0
LICENSED CONTRACTOR'S DECLARATION
Job Description
I bereby affirm that I sea licensed under provisions of claimer 9 (commencing
Met Sec0u ]pic) of Division 3Cf lie Business and Professims, Code. ad my licen4ls
in full to= andnffeel. -
TI-2ND/3RD FLR NEW WALLS
License Cl Lic. Y
Dale conuteror
CEILINGS/CARPET/DOORS/LIGHTS se—
ARCHITECT'S DEC n
I understand my plans shall be used u public records �$I CDPTJ-
Licensed Allo
OW NER-BUILDER DECLARATION
1 hstrut exempt form Ne License Law for the
(fvm Thu 1
lessm.rm
Mean, 1. Com: Any tiny Or County
followingroes.(anion ]1131.5, Business Proimprove.
dOruu
which requires • re ennsWc4 sur, rmprow, or opsin any
h remit i ucoure
Prior m its bens¢, also requires the applicant for such permit ro Ne a signed stammem
able
that hemencingwdpursumuntoofDiviouofdmConuiness LitenseLaw (C
Sq. Ft. Floor Area
Valuation \
Code) or
of ision Code)or
theBusinesssampling.
therefrom ad for An vi
Nat he b esempl thertfrom old the bub (Or the alleged eumptieaL AnY uolatim of
tham he exempt mads the
APN Number
Occupancy Type
Section 7031.5 by any applicant for a permit subjects the applicant m a civil penalty of
not meas Nan Ow hundred dollars ($500),
❑ I,uowrvj of the Nopeny,eamy employees with wagesuthe'vsuk compenation.
Required Inspections
will do the wodt and the me. boot rounded oraRernd Nuale(See. 7044, Business
ad Profession, Code: The Conuacml Lion Law does not apply m an Comer of
q P
property who bul Ida cr improves thereon, and who does such work himself or through his
awn employes, provided that such Improvements Comet intended maRered forule If.
however, me building or improvement h mid within one yes of completion. 0e owner.
builder will Mme the burden of proving mat he did not build or improve for purpose of
ulc.).
1. u owner of the property an exclusively contrasting with licensed conuuton an
construct the project (Sec. 7044, Business and Profesuou Code:) The Conuecton s Li.
.
cense Law does not apply to an owner of property who builds or improve thereon, ad ,
who coraco for such projects with a contracturl licensed pursuant to the ConuacnoO
License Law.
lam exempt under Seo. ,B&PC for this mason
Owner Dau
WORKERS COMPBNSATION DECLARATION
-
1 hereby a1@m under penalty of perjury one of the following declarations:
haw andwill¢annuma Cf Conserv fea Warkera Comp ere
Section 3700 of the I�bor Cade. for the periormente a( the
, proWdhi fpe do. 37MCode.for
for which rub permit Is lured.
r mi
1 haw ad will maintain Worker's Compensation legroom, as required by Section
Wof the Laor Code, for the performanteof the work for which this permit is issued.
'
My Workers Componsatiu Iuunnce Cartier end Policy number am:
Csmier.`>�E- /?Auq PolicyNo.: 10117
CERTIFICATE OF EXEMPTION FROM WORKERS
COMPENSATION INSURANCE
(This section need not he completed ITnhe permit is faronc hundred dollen ($100)
fir leas)
1 certify mal in the parfmmucc of dc weak for which this permit Is issued. I Na1I net
employ any person in any mmnerm As m become object to the Wol Compensation
Laws Cf Cuiforola. Dau
Applicant
NOTICE TO APPLICANT: If, slur making this CAmEcau of Exemption, you should
become subject In the Worker's Cmnpenution provisions of me Labor Code, you mug
forthwith comply with such provisions or this permit soil M deemed revoked.
CONSTRUCTION LENDING AGENCY
1 hereby salon that then ism construction lending agency for the perfurmanw of
the work for which this permit ts issued (Sm. 3097, Civ. C.)
Lenders Name
Lenders Address
1 tertrfy that I haw mad this application And tau that the above information is
CAMOCL 1 &I= to comply with all city and county ordinates and sum laws misting In
building construction. std hereby othorim mpremmuuve of rub city to enter upon the
show -mentioned property for InspeNan pulpmes.
(We) agree in an. indemnify cad keep harmless the City of Cupertino against
liabilides,judgments. costs cad expenses which may in my way accrue aguut card City
in consequmu of the grating of this petmil.
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON -POINT
Issued by: Date
SOURCE REGULATIONS,/
Re -roofs
Type of Roof
Sign¢¢ of Applicant/ Ij am
HAZARDOUS RIALS DISCLOSURE
Will Om applicant a fuuuc building occupant mom ter Asset. har mil mmteriu
as leaned by the Cupenia Municipal Code. Chester 9.13. ad the Health and Safety
COCA, Section 255324)? `
Oyu pJo
All roofs shall be inspected prior to any roofing material being installed.
If a roof is installed without first obtaining an inspection, I agree to remove
Will the applicant or future building Occupant use equipment or devices which
It humorous air conuminanu u defined by W Bay AMA Air Quality Mmagcmcnt
all new materials for inspection.
net?
❑Yes u
I ham mal the humdusmamrlab n
requirements under Chapter 6.95 of the Califo
nb Hcahh&Safety Cade, Secduns25505,25533 md25531.1 understand thatifthe building
does trot currently haw a until thu It is my rempnmihility m notify the occupant of the
requirements whrchm et 'Crani u Cf enilkate of Dc
Signature of Applicant Date
All roof coverings to be Class "B" or better
whorl
e r age D