05050055 CITY.OF CUPERTINO
BUILDING DIVISION PERMIT >uCU1 .TRACT'OR INF'02MA'TIQN
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BUILDING ADDRESS: SANTA CLARA VALLEY CORP PEEM"N.005050055
WR'400 STEV
S NAME: PERMIT SUE DATE
STATE SIDE PROPERTY 100 715 N 1ST
PHONE: SANITARY NO. CONTROL NO.
(408) 947-1100
ARCHITECTIENGINEER: BUILDING PERMIT INFO
ELDO ELECT PLUMB MECH
_op LICENSED CONTRACTOR'S DECLARATION
8 I hcmby arm Nal 1 am IkcuW under pmvismas of Chapter 9(commcnein[ Job Description
with Section 70M)of Division 3 of due Business and Pmfeuiou Code.ad my license is
mi ifall force andercea �pyS�6441 TI-1ST FLR/OFFICES/TRAINING RM/
ig? LannIC ass Lie.
t:ammehor c3—yCONFERENCE RM/DEMO/PAINT/ELECTRICAL
ARCHf CIS DECLARATION
1 understand my plane shall W wed as public records
3 U
>.trey Lk c:sed Prorwsimal
y OWNER-BUILDER DECLARATION
I 1 hereby tun ,(Sere that 11. wusin from iM Canlnnors t:A License Law for de
OO wthmItfollowingreason.permit
7031.5,Bualrc»and Improve.
doeou Count:
$ which mquhw•permit re cownel,site:Improve,de Permit
or repair any swmore
pat heor is eartpursu pursuant
W the lbevision of for sach Combowmiawfiie A nce Lnedsutemem
-F < Nnheislimn¢dpumlan7the")ofDiviouoflMConuacmhluxueLaw(CTac)or Sq.Ft. Floor Area Valu$tg.Yg000
y+ 9
(commencingwithSection7")of basilar nfthe Bwinmand
om.Any vi Codc)of
the he b esempl dem(rom and de buts for the si1cgW exemption.Any violation of
Sada 7031.5 by any applicant fora permit anbj me,the applicant to a civil penalty of APN Number Occupancy Type
.at more than live hundred dollars(M). .3 7 5 O'1 O 2 3
❑Lutwar oftw Property,ermyemployca with wagu N
esebsom compensadon, ) 02 r! 0..:v0 O
will do the work and me structure is notlmmarded oroffeled Tor Ne(Sec.7(3/4,Businessu 'n-
aad Pro lassloa Coda:The contractors Liaise Law dao set apply m an owner or ° g , '" RequiredlInspections
properly who builds orimpreves thereon,and whodoesauch work himselfor through his tLj l.�
own employees,provided dui such improvements am not Intended reoffered for oak.If, /
however.the building or improvement Is sold within ane year of completion,the owner- `,-
bulk&'will have the burdes of proving dust he did ne,build or improve fn purpose of �00G
ark.).
❑1,As owner of project
property,,Business euand Pmfesctines with:)Theed conuaemn se I' (��B�
cam La Nees owe(Sec.7014,weeroand ny whaiou Cade:)The esteems'.LI- W LU-11
�\lU (�./
came omp cosi nm apply a an owner of property-who sedbuildsp rs Improves Neean.and, !!11 L (Jl
whoe.Law.for such Projects with a eontsanaor(a)Ilaved pursuant m Nc Convsomrs
License Law.
am exempt under$ee, ,B&PCfor this revs
Kno to
Data
WORKER'S COMPENSATION DECLARATION
I hemby alarm under penalty of Perjury arc of the following declarations:
❑[ham and will maintain aCerti(twmof Consent w self-iaureforWadersCompen-
wait:,
want:
pro this
far by Sttda 3700 of Ne Wer Cade,far de pedommnee of de
for
whichh Nis pmnir is issued.
❑1 have and will maintain Workers Compeuadon Insurance.a required by Section
370:of Ne Labor Code.far the performance of the work far which this Permit is Issued.
My Worker's CCo�mpyensation Insurance carrier and Policy number am:
catncr.S'�'Q�C �Ml•P. Policy No.:�/Y!ffd pool t
CERTIFICATE OF&PTION FROM WORKERS'
COMPENSATION INSURANCE
(ITB soctinn need eat becompleted Ifft Permit Is resume hundred dollen(SIM)
lir ICU.)
1 anify that In the Mr...of the woh far which this Permit is issued,I shall mol
employ any person in try mannerso As m become subject to the Workers'Compensation
I.A.of California.Dam
Applicant
NOTICE TO APPLICANT.IL after at ng this Certificate of Exemption.you should
become subject se Ne Worecrs Compensation provisions of the Iebor Code,you muss
.J O forthwith comply with such provisions or this permit shall W domed revoked.
'T,..,' CONSTRUCTION LENDING AGENCY
[..,4 I hereby titian Nal ft.is a convection lending agency ford,performanuc or
C> the work for which this permit Is Issued(Sec.3097.Civ,C.)
WQ Lenders Name
W ,
7 z Lenders Address
U Q I certify Nat I hem need Nis application And sum dart me above inform W un Is
is,!'! carren,I agree m comply with all oily and county oadinaecas and sum laws mining he '
Q SVS buildingconstruction,ad bereby mNadm mpnxnuNes of this City a enter upon ft
W slave-mendonW property for Inspection purposes.
py (WC)agme W ave,indemnify and kap harmless the City of Cupertino sgsiwa
y liabilWes,judgmenu,costs and wpeww which may in any way amuse against said Clay
U 7 in consequence of Ne glinting Nis Permit. // .S• /7/ /
s7 APPLI ANT UNDERSTAN AND WILL COMPLY WITH ALL NON-POINT Issued by: Date
SQB{ R ULA S. _L-1,1'05
-
SitimlM �.atureofAppL, I'—� Dam Re-roofs
HAZARDOUS MATERIAIS DISCLOSURE Type of Roof
Will dm applicant or future building acupal atom errhandle hauNous material
Reed by the Cupertino Municipal Cade,Chapter 9.11.and de Health and Safety
Section x55314m � All roofs shall be inspected prior to any roofing material being installed.
❑Yue 6J -
Will Nc applicant or Iuwm building occupant use cq.1monat m devices which If a roof is installed without first obtaining an inspection,I agree to remove
emit hauNous air camminants u darned by the Bay Area Air Quality Management all new materials for inspection.
Diwin7
❑Yue war
I have read the huardow materials requirements under Chapter 6.95 of the Caliper.
niaHculN&Safety Cade,Sccdau255(15,15533ad25534.IwW.mmnd Nuirlhe building
deco al cutrcnlly hover a na4 ala is my napauibibLy m notary Ne necupanl of Ne
requirements mhmaa i Isseancearacenl0ciaca capamy. Signature of Applicant Date
DwnPrathatiredagem Date All roof coverings to be Class"B"or better