03040014 CITY OF CUPERTINO
BUILDING DIVISION PERMITCCSNfTRAC`�TOR INFOIR ATI AN
BUILDING ADDRESS: PERMITNO,
20450 STEVENS CREEK BLVD VENTURE BUILDERS 03040014
OWNER'S NAME: PERMN LSEUE DATE
1ROMETNEUS 1509 INDUSTRIAL RD 04/02/2003
SANITARY NO. CONTROL NO.
(650) 598-3999
ARCHITECTIENGINEER: BUILDING PERMIT INFO
BLDGMECH
= O PO O
alOp LICENSED CONTRACTOR'S DECLARATION lb Description
Thereby affirm that I am Ihenzed under pmvialop
ons of Chapter 9(commencing
with Section', )of Ivlsion 3oftite Bonn And PrafcealonACodClpo,end my license 13
IA full(once anil
Uan e b L DEMO
( ?7C�S
5'� ' .
Date Contra r r y
ARCHITECI'SD RATION
d r.dnd my plane shell he used as public records
Drs
it Licensed Pmfeui...I
it p OWNER-BUILDER DECLARATION
's<f 1 hereby affirm that 1 am exempt from to Contractors License Law for the
0 0 following mA,.,.(Saban NXI1.5.Business end Profunih ns Code:Any city or county
Ra$Pi which reyulrm a permit to cannruex.altar,impmv,demolish.m repair any slmclum
stn pilar In its bau,...u.0 requires the Applicant for such Permit to Ole uigned Ntemenl
FF C that he is licensed pursuant to the previsions of MA Contractor',Umme Law(CbApter 9 Sq.Ft. Floor Area VI wy1�IOn
N $ (commencing wit section 7=A of Division 3ofthe Business and Profestiuns Cuts)at $2388
Mat he Is exempt thuefrom and the bolt for Me alleged exemption.Any viol Won of
Section 7031.5 by any applicant for A permit subjects the applicant m a civil penalty of Occupancy T'pe
not mom than five hundred dollars(M). 3bU 8QTOO
❑1,u owns of the pmp ny,or my employees wit wegu a ftk mle compenudon,
will do to wok and thesuumure isnathuctol d oroffued fm We(See.7014,Business
and Professions Code:The Contractors License Law docs nal apply to in owner of NO ASSIGNED F"91314M t?Wfis
property who builds or Improves thereon,and who does uch work himself or trough his
Own employes,provided that such Improvmmu art not intended oroaered forsak.If,
however,the building w improvement is gold within ane year of compledon,the owner.
Wilder WB have the burden of proving tat he dial nm build or improv for purpose of / \
ole.)• l D
❑1,As ownc,of the property-am exclusively cmuacaing with licensed tmtnmos to \C
construct tita project(Sec.7004,Business and Profusions Code:)The Cormae s U. Cq
roue law does not apply manowner of property who Wilde or Improve thereon,and. V
who contracts for such pmjecu with a conlnemKU licensed pursuant a the Commode,
License Law.
lamexemptunder Sec ,B@PCfarthismuon
Owner Data
WORKERS COMPENSATION DECLARATION
1 hereby affirm under Penally of perjury one of the following deglerWons,
Inv and will for
eCenlfiase of the Labor
Code.
for Wohera Comf the
noon, r provided for mi Section 3700 of the IJbm Code,for the Pedarmsna of the
work for which this permit is Issued.
❑1 have and will maintain Worker',Compensation Insurance,u required by Section
3700 of to Labor Code,for the performance of tita work for which this permit le issued.
My Work is ore enutmA Ines..earner and Pollt Ise tae:
Genie Poliq'f.'a.: 7 n �3
r. ERTIFICATEOF EXEMPTION FROM WORKERS'6?,A
aTAIC f(j,.BOMPENSATION INSURANCE
(Bus section need not W completed if the permit Is forone hundred dollen(SIM)
or lug.)
1 ecnify td in the performance of the work for which this North ie luucd,I shall not
employ any person many manner an as in become subject o the Workus Compendtion
Law,of CAliforou,Data
Applicant
NOTICE TO APPLICANT,If.After making this Cenlficate of Exemption.you should
beceme subjw to the Workers Compensation provisions of to labor Cade,you mord,
.,O forthwith comply with such provisions m to permit Mall W deemed revered.„z,i CONSTRUCTION LENDING AGENCY
t—t 1Money alrmn that ten is a construction lending Agency for the performance of
the work for which this permit Is Added(See.3097,Civ.C.)
�W A lander.Name -
.7 z Londcrs Add.
U C 1 anify on.,1 have rod this Application and rete thal the sWv informal]..IA
Lis correct.1 Agra to comply with all city and county ordi mxv and sum laws relating m
O building construction,and hereby uthonm rtpresenutive of this city m enter upon the
W Above-mentioned p upsny for Inspemlan P.M .
gL (We)agree in UK,indemnify And kap hsrmleu the City of Cupertino against
In Ilablutieljudgmenis,costs and expcnus which may in my way smue against tend City
U 7 In consequence of the granting of this Permit.
F7 APPLICANT UNDERSTANDS AID WILL COMPLY WITH ALL NON-POINT Issued by: Date
SOURCE CU S. i�sd /
Re-roofs
I dueof ApplieanUContnclor Date
HAZARDOUs4aATEIUALSDISCLOSURE Type of Roof
Will the applicant or form building occupant some,rehandle hazardous material
As darned by tite Cupertino Municipal Code,Chapter 9.11.and the Huhn and Safely
este. y.25532(a)?s3z(a)? ❑Na
DAll roofs shall be inspected prior to any roofing material being installed.
Dy.
Will the applicant or future building occupant use equipment or devices which If a roof is installed without first obtaining an inspection,I agree to remove
.nit haurdous air contaminants u darned by the Bay Area Asir Quality Management all new materials for inspection.
District?
❑Yea ON.
I have rod the hascardous msteriW requircmenu under Chapter 6.95 of to Califor.
me Health k Safety Cade.Section 25505.15533 and
dmWouesu!f//nadlffCnuumcnoiys lav a tenmant tat h h muy resPe7ns5l5M3l1iry1 r
Amwu ndIM uocMillMillion,emMrdldiNng
ctprorYgdanaofACcnc o
"ga"ay Signature of Applicant Date
Owner or authorized agent Data All roof coverings to be Class"B”or better