04050143 CITY OF CUPERTINO °"' -"
BUILDING DIVISION PERMIT CONTRACTOR INFORMATION,
BUILDING ADDRESS: PERMIT NO.04050143 4050143
20658 STEVENS CREEK RINT)
OWNER'S NAME: PERMIT MUT DATE
OAKVILLE MARKET PLACE
SANITARYNO. CONTROL NO.
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ARCHr1ECTIENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
LICENSED CONfRACfORSDECLARATION ATION
UW Wrohya0rm that 1auretrpooldmaofCh 9 commencing Job Descriptiontion
wiCSaton]IXOofDiviNonlofOcRuunaandPmeuluuCa ,an0myliccnsis
4< wrmlf. er ._ (Q O WALL SIGN -
q z License el
eQFQ— Dale ConuuwLLr//.. CONTRACTOR: PACIFIC NEON
y oZ 1 undCrounJ my plans shall he used as pubic recoil
a.0 LicensedPrdcasional
OatNEm exempt
DECLARATION
E 00 1 mosso eRmm thes 1 em,Business
from dm ConlnnCoc License Law for she
0 0 followhich ma a permit
in ca L4 Bualnoss and w,demolish,
e tau h,or Cock:my city or county
$vi which requirns a permit no i til s the eller,impress,demob t or c a sig any statement�y prior m its lensed p al oral to rts lW applicant o for such Permitto's U lc se Law summcm
thathe ending wit pursuant to Nc provisions of theContractor'sBusiness Lmenwlaons Code)or
Sq.Ft. Floor Area Valuat�400
$
(commencing exewirh Section7") fDivision l chemeged amorphous
tlousAy Ai Code)or
Nal he is exempt thcrtfwm and dm bei for the alleged czcmpdon.Any Aided on of
Section 7011.5 by any appliant for a permit subjects the&Mia i to a civil penalty of APN Number Occupancy e
not mare Use five hundred dollars(s500). 35908018 . 0 0 P y TyP
❑1.uownuofthepupeny,ormyemployceswiwwaguuwe4wlecommnsatim.
will do thewons end these ComlenorILikeram Lawn to cale(Sec.]044,Business t
and proPortywh ons Code:The Conuectom nd who Lew ems not apply lf an owner of RD u' •Inspections
own,an wyces,provided rovcslhereon,andwho dome lowered
himrtaredselfor Wauth his )
own employee,provided or I war such improwmmu art not year
dei moaercd retain.mmer.
builder.Ne buildingft orimprovementishathwithin ane year of mproe(a,wepesc of
builder will love the Wooden of proving that he did not build m improv(or puryox of
um.). �J
1,uowner arcs pec.704am exclusively contracting with licensed ntrac
massLconstruct the s not (Sec.]014,weir of and Professions Code)The Con om 's LId,
who lawdocsnotapply Lean ownerofproperty who Wildstarimproves Certo!and \ 1
whocontractsfor each pmjecu with eeonuwwrtq licensed purtuanlmCe Conln love �s
Liaise law.
❑lam uempl under Bee ,B&PCfor Cb c;
Owner
phWORKER'S COMPENSATION DECLARATION �;):✓�
I hertby affirm under penalty of perjury oro of the following declarations:
ave and will maintain a Cenifiam of Camra mwlbinsum for WorkeYscompon-
uWn,as provided for by Section 17W of the LaWr Code,for the perfmmarme of dm
..,it far which his permit is issued.
0 1 haw and will maintain Workers Compensation luurana.as required by Sccdon
17W of we labor Code,for Ce performance of An work for which this pmtir is issued.
My Workers in rise on sunnmc rear tad Policy num4r tie:
Cyrier. P IypAyy Ne:�j
CERTIFICATEOFE% QNFROMWORKERS'
COMPENSATION INSURANCE
(ITE sec0ao need not W complemd If the permit is formic hundred dollen($101)
or less.)
I certify that in we performance of the work for which this permit is issued,l shall not
employ any person in my immerse as in become mbjest to IM Woomri Comp:nsadon
Lawa of California.Dam
Applicant
NOTICE TO APPLICANT:If,after making Cis Certificate of Exemption,you should
become subject in the Worker's Compensation provisions of the labor Code,you must
.J O forthwith comply with such provisions or Cu Permit shall M deemed maker,
'Z"' CONMUCGON LENDING AGENCY
(—rte 1harm tuffirre Cat them iso mmuuctom lending agency for Cc Performance of
a r�i IW work for which Cu permit is issued(Sm.3097.Civ.C.)
(T7 Q Lenders Name
z Lcndms Address
U Q 1 comfy that 1 have mad this application and sum the the above information is
!I. F correct 1 agree to comply Cid,all city and county ordinances and sum laws misting to
OU building construction.and hereby mthodm representatives of this city to an=upon the
r4 aWwfim,judgdpmpent for Inspection expenses
purpura
(We)agree to saw,indemnify and keep harmless tW City of Cupertino against
y liabiliuu,judgmenu,calm and ezpcuu which may in my way a<rncagainsr aid City
U 7 in conuqucncc of rendng of Ibis Pc t.
r7 APPLICANT D STA DSA LL MPLY WITH ALL NO Issued by:
Date
SQ ONS ��
-yam Re-roofs
DDI_V HAZARDOUS MATERIALS DISCLOSURE am Type of Roof
Will the applicant or future building occupant emrc or handle hrnmous material
as defined by Ce Cupertino Municipal Code.Chapter 9.11,and the Health and Safely
Code,Schon 15572(x)?
❑Ya pile All roofs shall be inspected prior to any roofing material being installed.
If a roof is installed without first obtainingan inspection,I agree to remove
Will the applicant it forum Wilding by ft Day Am.equipmentitQha of Mona ement P g
t na,:mous air canuminan�cfincd by Ce Bay Ama Air Quality Management all new materials for inspection.
Diarrict7 /
❑Yu u
1 have mail Celan msmamriabmquimmenuunder Chapmr6.95orLheCalifor-
his Pon"Sf5yCydc.Sanions25505,25511amI25514.1umfi thatrfdr Wilding
d cure y h a moa dot i y nsthdity u an
or Ce occupant of the
` re ren ColAe ma/ p m; m nracedrk.mof cyi Signature of Applicant Date
Ownm ar wrnanveJ,gcnl Dale I All roof coverings to be Class "B"or better