01050168 CITY OF CUPERTINO
nuu,DING DIVISION PERMIT CONTRACTOR INFORMATION:
BUILDINGADUIt ESS: PERMITNO.
OWNER'S NAME: APPI.ICAI'ION SUR HAD:
20833 STEVENS CREEK BLVII 01050168
• PHONE. SANITARY NO. CONI ROL.No
MMI REALTY 05/22-/2001
❑zZ ARCH]I'IiCT/INCINIi1iR: BUIkDING PERMIT INFO
µft O❑❑O BhI3G P.LECr PLUMB 1,1ECH
FLW CI CI CI CI
I-IC17NSED COMRACrOR'S UECLARAr1ON Job Description
5 H G 1 M1rreby n))of Ihm I um of the B under pmvisinfi of Chapter 9(commencing
C m� J :mndo3 , IIIc 11 : JI lint C h.anJ,ny license
wIhS ( ]lNlll)nfU
y i.i f II I and eff rn
rezrea
Due
u CI Il.� Lcp ,,rr�� �O
O6G Ua AHCH11'I C'r:S DICTA 16NW
W3Oa pl ..IrllheussJ . pbl'c records W DEMOLISH—A WALL AND_-..F�I'LLIN: DDORWAY. R
woe LicemedPro"'iomal �QeloM�'- 3 •CAN LIGHTS.
e OW N1: BUILDER DECLARATION
e =' I herchy chin..Jaw 1 tun ex.lnpl rm,n the Contractor',License Law,for the
I—>.T tollowing recon.(Section 703 1.5.Business and Professions Code.Any city or county
f_p which requires it permit to comwet alter,improve,demolish,or repair any.structure '
ce w prim 10 its osuance.alsorequires the applicant for Such permino file a signed statement
m than he is licensed pursuant n lira provisions ler the Contrition',License sew lchapler4Sq. Ft. Floor Area Valuation
(commencing with Section 7O 0)of Division 3 of the Business and Professions Code)
or than be is esnnpl thcrcfr.m:rod the basis Ind the alleged Wnflaion.any violation
of Smrion 7031.5 by any applteam for u permit subject%the applicant to a civil prom ly
of not rm,le than five hundred dollar(1501), APN Number Occupancy Type
01.as owner of the pr.p'ny,or my employee,with wages as their sole compen.mdnn.
will do the work,and the.structure is not imended or.IrcnJ for sale(Sec.7044.
B., and Profession,Cnde:'rne Cm onclol.,uam.e I.aw does aa,apply m:, Required Inspections $4549
reed ,a,.,who,build,ori unit es thereon,I J sen„does.such work himself .
or Ihr,light his own employers.provided that such improvements ala not intended ler
littlest for role.If,however,Ice building or i.tpnwun ern is and within one year of
completion.the owner.nwmer will have the burden of proving that he did not build or 326,32050. OL'-)
improve for purpose of sine).
01.asowner.1thepopeley.a,leesem,ivel,rommetln,withhecowticantorculIt, NO ASS16NED --INSPECTJONS '
swot the project(Sec.]tad.Business and Pmfes,i.ns C(Ne:)'1lr Contractor's r
and wh Law Joe,tun,such
no un ow.cr m'a emu( no het lids ler I Pur,un memnn.
and who.,ntracn ror noes pnjecn with u contraano b ild, ,,I.p...se,l ler tire
Contractor',License I.aw.
❑lion exa.npa under Sec. ,11&PC for this naso. 6
Owner
WUIi KI?R'S C(1MI1I7.NSAI'ION DIiC1.AHATION
I hereby affirm under penalty of perjury one of the follow ing declarations:
.' Cl 1 have and will ,ntrinuln a Ceniticam of Consent In mlf-inmre Iia Wader',
Compensation, as provided for by Section 3701 of the WM,r Code, for the
fell.....un c of the work for which this R'inti,i,Isvcd.
01 have and will maintain Worker,Compensation Insurance,as required by Section
3700 lel'Tho 4iM1or Cod,,fm the perfnm,ance of the work for which this permit is
issued h1y W,rker's olwoutioI Insurance cancer and Policy another art:
Caricry�l �R(Irl4 Policy No.:,y W -010
T19—
CERA1111CATION 01:ExEmicnON PROM W ORK12RS'
COMPENSATION INSURANCE
!Olin section need not a,completed it he It is(or one hundred dollar
(Hill or Icer.)
1 cc.ify that in me performmay,or the wild,for which This permit is issued,1
shall not employ troy person in any manner w a,a,beconto,-Ailed In the Workers'
C.... xati...Law, ,,Califnmm.Owe ,
Applicant
SOL ICE To APPLICAtV It IL after making this Cloodicale of Exemption,you,Would
Z become rdj'cl to l he Wnduk Conipen,nBnn pet iam oab
sf the Lor Cole,you wsr
run
Q Q forthwith eontply with w'M1 pmvin
vinv ler his pennil,null be Jrc,ned rcvo,eJ:
Z = CONS'FRUC{ION LENDING AGENCY
a 7. I hereby aOian that there is a construction lending agency bar the performance
of the work for which this permit is issued(Sec 31147.Co,C.)
Lendersum
Nc
Q Z Lender's AJAress
f..I C I Cc...iy tbm I have ra'ml Thi,npplinnion and ami thus the ntdvc information is
4e,, tr cannel.1 agree m comply with all city and corral,ordimurees,md.uric law,telling
Q [) a,building construction,and hereby vmM1ori7e representatives ofthis city in enter upon
y r� the above-vo-mtioncdro
properly fau,
r iPeaion pm
ao,em.
'F y (0.'e)agree In save,indenmifyand keep harndess the City II Cupertino aft I Is
y liabilities,judgments,costa and expenses which may in any way income against said
V z co,in romegnenee u1 the pmnling let mi,I,enma.
APPIACAN'1UNDERS'1'ANIIS AND WILL COMPLY WITH AI.,NON-POINT' Issued by, Date `
SOUHJiXI'J,iU�'ANS. // S/�R 1
Signor/a//rejjyy.I[[e�p..p c+,InaaComrac•tor ' Oa Re-roofs
HA7.1RDOUS NIATERIALS DISCLOSURE
Will Ile al,pnea,or thmre.mailding,mruwnn some orhandle hvanlous mancdal Type of Roof
vsdelinedbythe CnpeninoM Vnicipal Code,Chula--9.12,and the Health and Safety
Crude. sen".2533201, '.V No
0 yes All roofs shall be inspected prior to any roofing material being installed.
Will the applicant(it future building occupier use equipment or devices which If a roof is installed without first obtaining an inspection, I agree to remove
Iia baamdous air.o..Im..nun 'detinttl by the Buy Arca Nr Quality Ma.ugmncin
con, all new materials for inspection. Applicant understands and will comply with
OYes No all non-point source regulations.
1 have read the bnNous materials remiremnu,under Chapter 6.95 or the
Cal ifomin Health&Safety Code,Sections 25505,25533 and 25534.1 understand that
it the far Wi.g dam non..,.'ally metre a ncnan6lhut it i,III,n...mibi III, I,notify the
oxnup im cf the"may end,which must he mor prim to issuance ler a Cenllien'of
Gt°apan y //TM� 5Signature of Applicant Date
_R%L,gr25y °I All roof coverings to be Class or better
Owner or aummiied agent - —dare
OFFICE