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CITY OF CUPERTINO
Bmt.mrvcDrvlspoN. PERMIT
COl�i'LRACT�QI2'INkORMA.Tg1V;:
BUILDING ADDRESS:
PERMIT "04 0 2 0 0 9 9
00 STOKES A-V
OWNER'S NAME:
PERMIT ISSUE DATE
210 a) zs�.8y�y
SANITARY N0. CONTROL NO.
ARCHITEC YENGINEER:
BUILDING PERMIT INFO
j lopLC—S f}SSOC/ATC-S
BLDG ELECT PLUMB MECH
LICENSED CONTRACTOR'S DECLARATION
1 hereby affirm Nn I am licensed under Protlsioa of Chapter 9 (cammcuing
Job Description ts
p cyili� w
A
with Suti.n 7IX10) of Division 3 of the Business uW ProfGessipnu Code, nth mY lieenw is
Yat �:l"� gL J=^
infullfome cf"C 30 d 2O 6
Cleanse ClV 1J I LI O U
KITCHEN REMODEL/SKYLIGHTS/
°ate einem"
CONTRACTOR: BENCHMARK DESIGN i ' IU 2004
TS
I undersand my pl ns ahalll he awd v puRmao
BUILDING
Licomed Professional
OWNER -BUILDER DECLARATION
1 hoary affirm I nm exempt from the Conlns License Law for the
Co
following mown. on LD IA, Bwiva nth Re. aioa Cade: Any city a county
which requires • Permit re cnnstrw,, alar, impute, deermitt .,,Open my nmewn
emit t
for such Pcanil nice ssigned alsament
priormslcensed issuance. alerequires the previsions.(
wit pursuarl h) of the Conuacnr'a LiccucLaw (Chapmr9
Sq. Ft. Floor Area
Valttgtj,�t000
(dou Commencing of Division Pmfcainvi Calc)ser
(commencingwith Section of Division3 oftheeged
and momnd
Na, be Is exempt therefrom nth do, baso for the alleged esemptiu. Any violation of
APN Number
Occupancy Type
Section 7031.5 by any applicant for a Permit subjects theappliesu an a civil penally Of
set more Nn five hundred dollars (5500)
❑I. is mvur of the property, or y..pt,,. with wages as theha.la c.mpesation,
32649012.00
'
Re uired Ins ections
willtlo the work, and the structure inure intended oroRered fonale(Sec. 7044, Business
and Professions Cade: The Contecnra Lic mw Law does tit apply n an owner or
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property who builds or improves thereon. and who does wch work himself an through his
owncmpl.yces, provided Nal such improvements see not mbdn croaead forale. If,
however, the building., improvement is mid within one year of wmpledan. the ower -
builder will have tire burden of proving the, he did til build Or Improve for purpose of
exit.).
❑ 1. as Owner of the property, am exclusively contracting with licensed com an s to
1 1
conswM the pmjm (Sec, 7(114, Business and Professions Code:) The Conuacnr's U.
come taw does not apply to an.wus of property who build, or improve Nation, and.
who nntracts for and projects with a conuaenr(s) licensed pursunt in the Convector's
{.Leave law.
l ameaemptunder See, ,B&PCfarrhbmamn
Owner Data
WORKER'S COMPENSATION DECLARATION
1 hereby affirm under penally .(perjury mna.f Ne fallowing tlmlan0ans:
I have and will mainaln a Ctrificarad Consent towl6inaure for Wodmr's Campcn-
t w
atinn, a provided for by Section 3700 of Ne labor Code, for W performance of the
work for which this permit is issued
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❑ 1 have and will maintain workces Compensation I===, a required by Sedan
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37,.(the Iahar Code, for the perfmmnce of the work far which this Permit is issued.
My Worker's Compensation Insurance Cartier and Policy number are:
Cartier. Policy No.:
!
CERTIFICATE OF EXEMPTION FROM WORKERS'
u COMPENSATION INSURANCE
Clhts wnion heed nmbecompleo,d if ibe permit is forms, hundred dollars (SIM)
m lea.)
I cenify that in Ne Pc formmen Of the work for which this Permit b Issued. I shall not
employ any perwnm sur bccotPc wb�'ecl to Workers' Comparing
m
f. yh/-nth
laws of Calif. .I_*:
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N P A , afar making this Cculiicale of Ea n, you should
bcc me aoill, n the Worker's Compensation provisions of the labor Code, you most
forthwith comply with such previsions Or Nis permit shall be deemed revoked.
CONSTRUCTION LENDING AGENCY
I hereby affirm that Nen is a construction Lending agency for the rmfonnnn of
`
0m work for which this permit Is iaved (Sec. 3(197, Ci, C.)
Lender's Name
Landers Addma
1 certify that 1 Nes read this applicuf.n and nate Na iha shove information is
correct. I agree to comply with all city and county ordinances and also, lava missing to
-
building construction. and hereby admire representatives of this city to color upon the
above-memioncd property for inspection purposes.
(We) agree in an. indemnify and keep harmless the City of Cupertino against
liabilities, judgmena. costs red expanses which may in my way acesue against aid City
t
incos Permit.
APPLICCANT UNDNos ANstrunnoco Ding of WILL COMPLY WITH ALL NON -POINT
Issued by: Date I
SOL RCEREG ONS.
Re -roofs
Type of Roof
(3 0
S mof ApplinU omrmlOr - Da
RDOUS MATERIALS DISCI O RE
Will the applium or future building occupant ante Or himile hasrdous ro mrial
as dalmod by the Cupertino Municipal Calc. Chnwr 9.12. and the Health ad Safety
Cido, Section 25532(a)7
❑ Yes Au
All roofs shall be inspected prior to any roofing material being installed.
If a roof is installed without first obtaining an inspection, I agree to remove
Will the aWlicau or future building occupier sec equipment or devices which
ii ha'raNawairconumiunu as dc0ncd by Nc Bay Awa Air Quality Managcmcnl
all new materials for inspection.
Dniel?
❑ Yes r�/u\
I have mad the hasrdow maaiiats requirements under Chapter 6.95 of the Califon
HplN&Safc,yC .Satioa 25505,25533 and 25534.1 understand than iftle building
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. nor eunentl a tenni, oil i, U my ren ,hili y 'notify tis compnt of the
mquimmcna mwlbemelprior u aCemr Co.way
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Signature of Applicant Date
b
All roof coverings to be Class "B" or better
owner or vKcrohd4Cnl ons