00070011 CITY OF CUPERTINO
BUILDING DIVISION PERMIT CONTRACTOR INFORMATION:
BUILDING ADDRESS: 51�I cu.. V�IIQ✓1 L,D:ZCJI,ICN/iG`— PEKMI'PNO.
OWNER'SNA 20833 STEVENS CREEK BLVD 1Ll I lISS- szsvILILA.I.K)
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PHONED STEVENS CREEK OFFICE CEN ER AS (,4,09) 2.66-000—Ooo SANITARY N(67�QJCpG7d
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O ZO ARCHITECTIIiNGINEER: BUILDING I'ERhll IINFO
IILDG ELEi PLUMB MITCH
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0 ,J LICENSED CGN'nsed uIv'SDEion—I CION JOE) DCSCIIptIOn
O 7 O hecby alllrm 1M1m I ren licensed ander pnovirionc of Chupmr 9(conunenaing
rr,_C J with Scnion7lxxlµ,l Division3ofthc Business and Pmfcs.i...CCode.andmylmcnu
am<, Is in tall l noc ;Iad effect.fy Lie., 529 1
63
µaz < Lican,e Class 4J -
y, V Dam cnnlGmmr SS11 (�
3 a u ARCIf1TiiC1"S DECLA�CI'ION
°g IundcmtaOdin)plan.snhdlbeused aspabficmennlr INTERIOR DEMO OF OFFICE BUILDING
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pO Licit Pmtv,aunal
it OWNER-BUILD17R DECLARATION
in I hereby allirm that 1 am exempt from the Contractor's License Law for the
C 5< Iitlowing n t.(Sc,!....9031 5,Ilnsi end Vrol'en ns Cade:Any city a county
a near .
x o which rcyui permit to amnmct,ober,intpmsu h crinis I lir repair soy swcmre
n, primmnxcnsedp.Wnnnito dre Naapplicant for Contrarntinnicensele a Law
(Chmnwm
that ne,n6n,avdpmmuant tante pmvnvisin 3 if andPelww tchepter9 Sq. Ft. Floor Area Valuation
fa,mmoneis with Scnion 7rxxp of,,havon 3 of the li vdi is and PndAuy li Code)
or that M is exempt therefrom and Ibe basis lin the alleged cxentp to Any violation
of oolmSection e man % any hundred
doth far a perms subjects the appliaam m a civil pemthy
of Dol more Nun nvc hnnJmJ Jollary(SSM). APN NIIT76CC DGWp:LLl{y1Tpe
C3 1,as owner nl'the pu,,n,.many anhpluyces with wages as'hu—le emnpmtxation. bC` t�7
will Jo the work,and the%mcmm is not intended or olrcred for sale(Sec.TA4.
limine"not Prms"i'a"Code:ELe Cnotmanr's License Law door not apply In apt „ "'2051.
Wuired Inspections
r of pmNmy Who Wilds or impmvex thereon,and Jr.wdoes such work himself 3263
or(throughhis own aoployees,noodled that such improvements are not intended or
oWred Iia rale.It,however,the building or improvement is sold within line year of
unpletion.the owner-builder will have the burden of moving that he did not build or NO ASSIGNED INSPECTIONS
improve for ginum,.1'sam).
❑I.orowner nl the p(See Wild.am excbusiness a amuaeting with Ilcc:)T e Condi ars m
Bas o the of%he (Sec. am Easiness and Profit Cale:)The unnmcmr i
ljiceno,I.nw tow not apply m•an awna'of prnpeny who hulds or ingm,ves thereon,
and who contracts for such projects with a contmcloo,j licensed pursuant m the
❑lam eaempt under Sec.• .H&1'C for this rceu
Owner Dale 3v/
WORKER'S COMPENSATION DEChARA'1'ION
/ 1 hereby atEnn under penalty of pa jury one of the following dmlaration, ,
111 O 1 have and will maintain a Cenif ate of Conwal to self-insure for WorAcr's
Coo.pensation, as provided far by Sution 37m) of the Labor Cede, for the
performance of the work for which this permit is issued.
❑1 have and will maintain W leer's Compensation Insurance,as squired by Section
7700 of the Labor Cale,for the pert nmence of the work for which this permit is
issued Sly/`J(I kk/e,,('�Con pc ;pi once carrier and Policy number arc:
cmrier:y'Vnr` O�h1s Policy No.:
CER rIFICATION OF EXEMPTION FROM WORKERS'
COM PCNSATI ON INS U RA NCE-
(Ibis avn lath need non lie cmnpleled it hhe permit it for line hundred dollars -
M00)lir leas.) '
I mord,tlta in the pe.nnnanec of the work far which this permit is issued.I
shall nut employ any person in any manner so m lit bnemn,stbjea to the Workers'
com,enraion Laws or Cal Iturnio.Date
Applicant
NOTICE TO API LICAN'I':IL after making this Cerld"We of Iisemplion,you xhoad
Mellow subject m the Workers Compereation pmvisions of the LdWF Ede,you must
Z p 1'anhweh cunmly wlnh such pnrvisionx lir Nir penult.hull ha Acemcd ruvuACJ.
Fy CONS'TRULTION LENDING AGENCY
ai1 hereby affirmthat them is a amNaaclian Iendoug agency for the performance
of the work for wI,i,h this permit is issued f&c.91197.Civ.C.).
L1<nJer's Name
� Z Lender's Address _
V C) 1 cenify that 1 have mad this application and state thanha above information is
Iz P cancel.I agree m comply who Ill city and county ordinnncw and spite Tawe rclming
V thb,building atrvction.and hereby authorim representatives ofihis city to enter upon '
e dovo-merominncd Pmpeny far inspatinn purpoxes.
F y (We)agree tosavm indemnify and kap hand—de City of Cupcn'ma ugmIN
(Al Iilthado cN,jnJgowntx,costs and expenses which may in any way Deane against said
(.7 ,Z City in nm.wquence of the gaming el this permit.
APPLICANT UND b STAND AND WILL COMPLY WITH ALL NON-PONT Issued by: r Date
SOU R.GU ONS, q/s GF
1�
Signature ill App icaoocnmmaar love .Re-roofs
IfAL(\RDOUS MA'I'F.RIALS DISCLOSUREreohaud
wwy heCvenmouldu<btdldingacupu,m,9.e2,and le lbrildourmateell, Type of Roof
m dented w the Cupcnino Municipal Code.chapter 9.12,and the Hcann and Safety
Gala.ticalinn 255721m9 '
Oyes 0 N - All roofs shall be inspected prior to any roofing niaterial being installed.
Will the applicamor future building occupant use cgmpmemordevices which 11'a roof is installed without first obtaining an inspection, I agree to remove
'mit hannlous uir c,marm ants as defined by the Bay Ams At,Quaint'Management
District. all new materials for inspection. Applicant understands and will comply with
❑Ye, 0 N all non-point source regulations.
1 have mad the hamrdous materials requirements under Chapter 6.95 of the
CaIJ'ornim I Icullb&Safely Cu Ic.Sections 25505,25533 and 25534.I undersand that
if the building uses nm currently have amount.that it is my resrym,iNIu,m notify the -
use cuptml of ph/c require
lnh¢h in u.a be non prior at isxu:mee�ull if Ccnineata of
/e Signature of Applicant Date
Owner or aathnsized agent ,rte All roof coverings to be Class "B” or better