03100149 CITY OF CUPERTINO d' A? sa sem'+. ' <6 '^` `'" '�-� "'
BUILDING DIVISION PERMIT CONTRACTORANFORMATION
BUILDING ADDRESS: _ LAMCKE CONSTRUCTION PERMIT No.03100149
7)71, qrr)Kpq
R'S NAME: 855 CIVIC CENTER DR . PERMIT ISSUE DATE
"EI (408) 985-7625 SANITARY NO. CONTROL NO,
ARCHITECT/ENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
0 0 0 0
X00 LICENSED CONTRACTOR'S DECLARATION Job Description
I U C I here y firm IAet 1 am littuce under provisions of Chapter 9(commencing _ P
w with Scmio, xp of Division)of the in "and Prafcssiuv Codc.uW.1 license is
=� in fullfoteeandeffak ✓ � REVISION--IN HOUSE USE ONLY
s z License Clans Lic.N
rale ARCHITECTS BCCnRaeC1LARATIDN NO NEW PERMIT ISSUED/ORIG. 303070046
q D
i 2 1 understand my plans shell be used as public records
Mu
°off Licensed Professional
,3 OWNER BUILDER DECLARATION
)0 0 1 hereby.(firm that I em exempt from the Conharmo License Law for the
p 0 following reason.Section IIDLS.Business and aw.Prefics%ionsdemolish,
Calc:Any cin Of county
5$ which rets Issu aprmoreconswe,alar,improve,h permits nuts a sig any Structure
y primmitsiensedp pursuant
Novisio antsof forthe sucCm permittoLice
e0 aLmv(Cned ammem
ib< (In,In commecing wit purse..7 the Of Division 3theeBoado . ad Prof Law(C Code)
Sq.Ft. Floor Area Valua[io�q 107
Rea
(cat he is
(commencing Sermon Hand of Division?nftheeged exempton.Any
Cnde7 tar
Nat he is exempt therefrom and the buns for the allege.exemption.Any violafion a(
Section 7031.5 by any applicant for a permit subjects he applicant m¢civil penalty of 3 ABF M(blier 0 0 Occupancy Type
not mons Nan five hundred dollen(M).
❑1,a owner of the property,or my employees with wage as their sole compensation,
will do the work,end Ne Structure is not intended or offered for sale(Sec.7004,Business
and Pol easions Code:The ContsactDes Liana Lew does not apply to an owner of Required Inspections
property who build,or improves Nerenn,end who donssuch work himself or through his
own employees,provided that such imp evemenu are,not intended or offered for Sale.If,
however,to building or improvement is sold within one year of completion,the owncr-
builder ,will have the,burden of proving Nat he did not Wild or improve for purpose of
Laura.).
I,es owner of Ne property.am exclusively contracting with licensed contractors to s�
stroct Ibe protect(Sec.7(sM.Business and Professions Code:)no Connotes'.Li. U )
cents Law does not apply to an owner of propeny who Wilds or improves Neeson,tad,
whocommctsfor ouch projects with aemmnnor(s)licenudpursuant to the Contractor's
License Lew.
Alam esempl u r ee. B h P C fonIn Sao
Ossa D
( O R'S comPENSAilobiD ION
1 hereby aRrm under Penally of perjury one of Ne following declaration:
I have and will mai main i CeriOoate of Consent o ul6insum for Workeri Compen-
sation,u provided for by Section 3700 of the Labor Code,for the perfomencer of the
work for which this permit is issued.
I have and will maintain Worker's Compensation Insurance,as recruited by Section
37M of the Labor Cate,for the performmce of the work for which his permit is issued.
hl�Vor Ya Ccoomuumn lnwnna carie end Polity umber au:
C
CERTIFIC COMPENSATION
WORKERS'
COMPENSATION INSURANCE
(This section need not W completed if the Permit Isfor one hundred dollars(SI W)
or has.)
I sandy that in the performanec of Ne work for which this Permit u ounce,1 Nall not
employ any Penson in any manor an as m become soblecuo tW Workeri Compensation
Laws of Califomia.Dam
Applieam
NOTICE TO APPLICANT:If,after making this Cenificatc or Exemption,you Should
become subject to the Worker's Compensation provisions of the Learn Code,you must
�O forthwith comply with such provisions Of NMem rm i t shall W deemed revoked.
CONSTRUCTION LENDING AGENCY
I hetehy union Na,Nem is a construction lending agency for one Performance of
x>
to,work for which this Permit is issued Sec.SIM?.Civ.C.)
37 Undeh Name
3.Z Lander's Address
1 certify that I have read this application and shoo that Ne above information is
y F Sorrell.1 agree to comply with all city and county ordinances and state laws relating to
DU building construction.and hereby authorin representatives of this city to enter upon one
a ahovaamentioned property for inspection Von.&
(We)agree to Save,indemnify and keep harmless Be City of Cupenum against
ll liabilities,judgments.coats and expenses which may in any way acme against laid City
J Z in consequence of Ne grami ng of this permit.
APPLICA UND STANDS D WILL COMPLY WITH ALL NDN INT Issued by: Date
so URC UL IONS. /9
sic o icam/Cohmron Dow
e-roofs
HAZARDOUS MATERIALS DISCLOSURE Type of Roof
Will the applicant or future building occupant stare or handle haoto ous material
as dented by Bre Cupertino Municipal Code.Chapter 9.11,and the Health end Safely
secdon 25531(¢)?Yu '1�o All roofs shall be inspected prior to any roofing material being installed,
Will the applicant or future building Occupant use equipment at devices which If a roof is installed without first obtaining an inspection,I agree to remove
It h4aardous air contaminants as defined by the Day Arca Air Quality Management all new materials for inspection. -
ixuic19
❑Yes $IN.
I have mad Ne haraNrms materials requirements under Chapter 6.95 u(thc Cali for
ria Health StSafetyCoM.Seem.15505.755)3 and 15534.1 understand Nu if the Wilding
dos curefly hex e te m4 that it is my responsibility m n 'fy IM Pant of be
req ' hichom melpdorwhamane..f. re rfolcu Sy' SignatureofApplicant Date
D m anthmfald S,cm D 2� ,e All roof coverings to be Class"B"or better