03090243 CITY OF CUPERTINO '�A
BUILDING DIVISION PERMIT ,CONTRACTORINFORMA"CION d
BUILDING ADDRESS: s PERMIT NO 03090243
!2n730 STEVENS 9REEK BLVD
y� `WNER'S NAME: PERMIT ISSUE DATE
E: SANITARY oci. CONTROL NO,
ARCHITECfIENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
I� 0
!op LICENSED CONTRACT'OR'S DECLARATION )Ob Description
i 1 hereby affirm the,l em lixnsed sande pin sia a of Chapter 9(commencing p
.m with rel 070)(ha(Divialon]of OsloIiya_,stpnd Pmfcuione Cndc,endmyliccnmis
< in tali endcffec,. e Le'f M SIGN
Z Lice
Data camsacror CONTRACTOR: FLUORESCO LIGHTING & SIGNS
QQ ARCHITECTS
DEECLOA000IT
t rZZ 0,� ,A& .udmyplmsehallMuud tic records
16s.
Licensed Pndcsaionel
v,
OWNER-BUILDER aexemptfDECLARATION
y I hereby Maso Ali ct on I ore exempt from Ne Contrpersio Co License law co the
m 0�, (allowing rtuoa Peron it IIonstr t.shot, and improve.
dcroli Coot:Any tiny or smwny
which requires a peroso it)ra cnnurom,dna impress,h permit
t or repair ed a,rxwn
5z� poor In its issuance,also requires the applicant for such Pcrmiuu Olcasigncd statement
that he is licensed pursuant in the provision of he Contractors License Law(Chapter 9 Sq oof a t 5OO
2 $ (commencing with Section 7")of Division of the Business and Profession Code)or
that he is exempt therefrom and the beau for the alleged exemption,Any violation of
Section 7031.5 by any applicant far a permit subjects Ne applicant n a civil penalty of 3 pant; Type
Mn mart Nan five hundred dollars(5500). l
C I,As owner of the progeny,or my employees with wages AS their ale compensation,
will do the worked theawauu isnot intended or offered for sale(Sec.7044,Business Re aired Ins eCl101ts� J
and Profession Code:The Constitutes License Law don do,apply in sa owner of p
property who builds or improve d,euon,and whodoessuch work himulforthrough his 101 - FOUNDAT ON
own employee,provided that such improssmenks are no,intended or offamd parade.If. lO3 — U}-',ER
however.the building or improvement is sold within one year of completion,the owner
builder will have the burden of proving Na,he did not build or improve for purpose of 104 — REBAR
We.), 105 - ANCHOR BOLTS
❑1,saowner of Neproperty,,Bexclusively ProfessiContracting s with:)meedcanVator's t.
commathe
oes not,pplyse anownerofproprtywho Wilds oe:)The Contractor's Lt. 304 — ROUGH ELECTRICAL
came Law doar such plynsn aith aofpropcny whosedporimt to tit thereon.and, 505 — FINAL ELECTRICAL
who
nse Us u for pmjccu with a contnnor(q licensed pursuant so the Comnenfs
0eau law. 514 - FINAL PUBLIC WORKS
❑I am accept antler Seo. ,B&P C for this mason
Owner Dan
WORKERS COMPENSATION DECLARATION
1 hereby affirm under penalty of per)ury arc of the following doelamitirve
I have and will meinuin a CcnlOxu of ConunHo ul6inaun for Warkce.Compcn-
sation,As provided for by Section 3700 of Ne labor Code.for the Nnannnce of,he
work for which this permit is issued.
C 1 have and will maintain Worker's Compensation Insurance,As required by Section
3700 of the labor Cade,for the pwfonnance of the work fwwhich this permit is issued
orkerifyop,peyyupdionlnu camera licy remiss,dm:
cr. 'CERTIFICATE OF EXEMPTII�NFROM WORKERS _O�
COMPENSATION INSURANCE
mils section need not he camPlend iOhe permit is foram hundred dollen(SIM)
lass.)
I edify,he,in the performance or the work for which this Permit is Issued,I shall not
employ any person in any moneran As In became Subject 0 the Worker'Compmunion
Laws of Calipomia.Dan
Applicant
NOTICE TO APPLICANT:If,after making Nis Certificate of Exemption,you should ,
become suom,to the Workers Commission provisions of the labor Cade,you mus,
z forthwith comply with such prevision or this peromi shall be decreed revoked..
Z O CONSTRUCTION LENDING AGENCY
I hereby affirm that then is a construction lending agency,lot use xr(urmanee of
5: the ,it fur which this permit is issued(Sec.3097,Civ.C.)
31 Q Lender',Name
7 z Lender'sAddress
;)0 1 cenify Ne,l have read this Application and sou,hat Ne shove information is
S. f-` comae,,l gree to comply with all city and county on inamos and sun laws mixing 1.
�U building construction.and hereby authorim repmsema,im of Oi&city to enter upon the
'hove-mentioned property for impaction purposes
ti C (We)agree to save,indemnify and exp harmless the City of Cupenitw Against
sn liabilities.judgments,costs and"penes which may in any way acme against said City
j in eonsecommi,of the granting of this permit.
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT Issued by: Date
SOURCER ULATIO k
•�7� Re-roofs
Signature ofApplicaHAZA HAZARDOUS
Del
HAZARDOUS MATERIALSDISCLOSURE Type of Roof
WIII the a Cuf MMser(Muni building e.Chapter
stem or handle huuduu,maned
C dented by the Cupertino Municipal Code.Chapter 9.12,and the Health and Safety
CWe,Section 25532(x)?Fl Yn All roofs shall be inspected prior to any roofing material being installed.
Will the Applicut or furan building arupam sou cyvipmxl w devices which If a roof is installed without first obtaining an inspection, I agree to remove
hevsfdnm si,chosen...is As darned by On Bay Area Air Quality Managemem
Diai ic0 all new materials for inspection.
C Yes _�,Nu
1 have real the ha'ramnus materialsmyuiromenu under Chepur6.Y5 of the Califnr
niaHwlthh Sd(c,yCodc,Secuom 25505,25533 ond25534.I understand thatif the Wilding
does no,came t y h vv a tenant.Na,it is my respamihilay n notify,he w¢up r,of Ne
rcyulmmcnu whit st be mss br n issuance are catureaa or=y.axy. Signature of Applicant Date
YAll roof coverings to be Class "B"or better
Ownc amhon'rcdegcm an