04050053 CITY OF CUPERTINO - *� r-aax?a. ="xi ""��'' y
BUILDING DIVISION PERMIT GONaTRACTORINFORMATtON:
BUILDING ADDRESS: SIGN A RAMA PERMIT Np.4,050053
21 V
OWNER'S NAME: PERMIT ISSUE DATE
BOSSABELLA DAN
E; SANITARY NO. CONTROL NO.
4082437388
ARCHITECTIENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
LOa LICENSED CONTRACTOR'S DECLARATION JobDescri tion
I hemby affirm shot 1 am licensed under prevision of Chapter 9(commencing P
with Section 7")of Division 3 aftBmittessvit Prof acoria,end mylic la
mtm.dcl` lieffect. SIGN--BOSSAIBELLA DANCE STUDIO
S ? License Clnr Lm.g
g If
Dam Commem"
CHf1ECr A
Ion Land my PI asatollW used u public ramds
U�U I
3 Licensed Professional
OWNER-BUILDER DECLARATION
02 I Wrobe.(sere that 1 1. exempt fmtn the Convenor's License Law for the
o O (allowing moron.(section]D3 t.4 Business and are.demolish.
Curie:Any city or county
x$�i which mquirea a permit m consumer,inter.improve.demolish.or repair my[wcmm
FO prior to its inuaae.also mquimslW applicant for each Permit rile a signed.Latemenl
;FF< Ran the Sq.Ft. Floor Area Valuation
u
C3� (commencing with Section 70)(fof Division 3 of the Dart. .ad Prefuschme Coda)Or `
C that he is aumpt therefrom and the boon fm the alleged exemption,Any violation of
Section 7031.5 by any applicant fora permit subjects the applicant to scroll penalty of 3 262;AQWBa%e3O 0 OCCU anC e
not mom Wan Ronhundred donna(SSD). P Y Type
❑I,as owner ofum property,Or my employees with wallet an Weir sole compensadon, 6 r��
willdothework,andthesWcmmis Nat Inlerldedoraffe dforaale($ .]Oa,Business
and Prefession Cade:nsc Convertors License law dose not appy on an owner of X P, al' nspecl, nsproperty who buildsorimp fives Wamen,and whodausuch work himselforthreugh hisown employes,provided that such imprewmanto ale not Intended or offered for abe.If. Ihowever,We building or Improvement is said within one year ofcompledon,the Ownerbuilderwill haw We burden of proving that W did not build or improve for purpose a(
1.u Owner of the pmpony,am exclusively contracting with licensed chaichairwomenmto
wmvuct the project(Sce.7010,Be ..end Pmfetion Code:)The C sommure.U.
cease law does not apply to an owner of property who WiIN or imprew thereon,and
who contacts for such projects with a commetoKa)licensed pursuant to the Convertor's
License Law.
D lameaemptunder Sec .BkPCfmthismamn
Owner Date
WORKER'S COMPENSATION DECLARATION
1 hereby afnmt under penally of perjury,ane of the(allowing decleration:
haw and will maintain a Camille.,.of Coram m self4wre fm Workers Compcm
1�37W
r,a pmvlded for by Section 3]00 of the Labor Code,for the performance of the
for which this permit I.issued.
haw and will main Was Worimes Compenmom Insurance,as Laquitad by Section
of the labor Codc.for We performance of the wok for which this permit is issued.
Wo kefa Campenaa Inursae carrier and Policy number art:
IN
Polityry,--WWaayy _
VCA ^0^ • P1RWORKERS'
COMPENS INSURANCE A'ION INSURANAN CE
(This action need nothecompleted if the permit Is Intone hundred dnllan(SIDE
ser less.)
1 certify that in the performance of We wok fur which this permit is issued,I Nall not
employ any person in any manner an as in became subject o the Workers'Compemallon
lawn of California.Dam
Applicant
NOTICE TO APPLICANT:If,after making this Continents of Exemption,you Nould
became Subject to the Worker's Compenalion provisions of We Labor Codc,yam mum
,z fOMwith comply with such provision or this Permit shall W diamond revoked.
Z O
55CONSTRUCTION LENDING AGENCY
..,F Ihemh ono that them is a construction lending s c
nfor We perfurmarna at
We wok fur which this permit is issued(Sec.3097,CN.C.)
GQ Lender's Net.
.7 Z Lender's Address
V 0 1 certify that I have Lead this application and slow that the show intonation,it
F contact.1 alae to comply with all city and county ordinances and sum laws Labeling in
building construction,and hereby authorize representatives of this city to toter upon We
0
abovamenudgmentored ts.cry fm inpeNnn purposes
(We)agree m sew,indemnity and keep harmless the City of Cupertino against
U
Liabilities,
umcm enu,costs andaxycnna which may in any way accme against aid City / x
V z AP 11CA T of the nnf f this M �_41
APPLICANT DSA ILL COMPLY WITH ALL NONPOINT Issued by: v
SOURCE S.
Re-roofs
gnu,. fApplicaAZARDOUS MA DISCLOSURE De Type of Roof
WIII plumLar(vivre bis' upor'smLa or handle haardous material
a defined Cupertino Muat otic,Chapter 9.13,and the Hca1W and Sa(ey
Codc, on35533(q? All roofs shall be inspected prior to any roofing material being installed.
0y. o
If a roof is installed without first obtaining an inspection,I agree to remove
Will We applical or future bui n{ace m Lax eyvipmenl or devices which g
haysrdnus air contaminants u m at by tW Bay Area Air Quality Management all new materials for inspection.
vin?
Dyes
I have mW the hvsMmts materialsseyuimmcnts under CNpter6.95 of the Gli(nr.
dianatco Safety[.@,Sa9am 5.255)7 d]SS3d.lurale rslaM dutiflhc Wilding
Jose teat curentl a tenon t u ponsea lily tonary Ile Occup of Nc
Le mi.men I ore W or an rc.m0 pan y Signature of Applicant Date
saner a antnn assn, _ D„ All roof coverings to be Class "B" or better