04030173•CITY OF CUPERTINO
INkaU'RNiA'I01„'
BUILDING DIVISION PERMIT(J,11td�
BuaDING ADDRESS:
BENCHMARK DESIGN
PERMIT ND. 04030173
HER'S NAME:
MILLS TTqF.()p0RE
1382 MARIA WA34
PERMIT ISSUE DATE
..ONE:
SANITARY ifP OL NO.
ARCHITEC (ENGINEER:
BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
LICENSED CONTRACTOR'S DECLARATION
Job Description
1 hereby affirm that 1 am licensed under prevision of Chapter 9 (commencing
with Section ,.f Division 3 of the Business straltFilufachous Code, and my liciums,I
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in ren lnrce ryidffreQ�_' LossZ" �°
EVISION' -IN HOUSE USE ONLY
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Dai _cmtwcn
NO �RMIT ISSUED/ORIG. #04020099
W ARCHITECT'S DECL�S TION
1 understand my plans shall be used u pub c mcoNs
✓�,
Licensed Professional
OWNER-BUILDER DECLARATION
1 hereby .(Sere 1 exempt from the Contractor's Law for the
lV
: Any c
IIDL5, Business Prolusions Code: Any city in county
following meson. on 1.
r,
-
itad
a Permit t cnnswcL aheG Wprow, repair any swcture
which Permit
which
_
its issuance, requires h Permit t fl Cn(
applicant of forsuch panes License Law( sume(Chaplet
pllor e1 i 31Ynsed
heialieenxdw�ammtheproWaipnnrmeconitaamrauannxl.w(chapmr9
rsuanththe
Sq. Ft. Floor Area
Valuation $0
that p pro
(emenoneft with Sutitat7WO)of Division 3 of the B.m. and Profession. Code) or
1 . dist be Is uempt thorefrom and the basis for the alleged exampnon. Any violation of
APN Number
Occupancy Type
Semon 7031.5 by any applicant for a permit subjects Om applicant in a civil Penalty of
not mare than Rw hundred dellen ($500).
32649012.00
0 1, as owner of the property, or my employees with wages a their sole compensation,
Required Inspections
will the fon an B
Comi[nor's
Licdedmoaertd
t apply in mer or
ons Cade: The Conmctor'a law does not apply lf an owner of
and pmrsub ou Co he
9 P
wh ndwhot datasuchwork his
pro pertywhobuildsorire
property
oraelfedthrougM1
that such Nrertd for
awn employees, provided that inch Improvements are
m Ironer,
is hath within one year or completion, Ne ownco
however. Ne building or an you
'
den of rmant
builder will have the burden of protan{ Net he did not Wild or Improve ran purpose of
u1eJ.
❑ 1, as owner of the lumpily, ily, em exclusively contracting with licensed convectors to
convect Ne project (Sec. ]OM, anobac a and Profusions Code:) The Connector's Lt-
came law docs not apply to an owner of property who Wilds or improves flu mon, and
who common; for such projects with acantracmr(s) licensed pursuant to the Contractors
License Law.
❑ I am attempt under Seo. ,B&PC for this main
liar Date
WORKER'S COMPENSATION DECLARATION
I hereby afflIm under penalty of perjury one of the fallowing decelerations:
0 Thaw and will maintain a CartiBum of Consent to self-insure for Workers Compton.
nation. as provided for by Section 3700 of the labor Code, for the performance of the
work for which this Permit is issued.
0 I haw and will maintain Worker's Compensation Insurance. as required by Section
3700 of the Inbar Cade. far the Performance of she work for which use Permit Is issued.
My worker[ Compensation Insurance carrier and Policy number are:
Cartier. Policy No.:
CERTIFICATE OF EKEMPDON FROM WORKERS'
COMPENSATION INSURANCE
(Thlssecdon nwd not he completed if the Permit Is formic hundred dalim n W)
or loss)
I coolly deal in the Perrornmcm a the work far which this Permits issued. I shall not
employ any person in any in x mmLecamr}pbjcl rZMorkeri Compen[etlon
Laws Of Celifand T^IT
_ g
Applicant
NOTICE TO A71PLICANT54LIefter making this Ccnificam of Exemp ren, you should
Wcome subject in the worker's Compensation provisions of the Labor Code, you must
forthwith comply with such provisions or this Permit shall be deemed revoked.
CONSTRUCTION LENDING AGENCY
I handby den theme is a construction lending agency rn Ne performance of
which d(Sce30
menLe work for which thio permit is issued (Sec. 31197. Civ. CJ
Lender's Name
LcnderY Address
'
I certify that I ban read this application and [um that the above information is
Comem. l agree to comply with all city and county ordinances and stain lawn relating in
building convection, and hereby anthadra representatives of this city to enter upon Nc
above-mentioned for inspection purposes.
property
a City Cupertino
4 (We) agree to taw. indemnify and keep humleas the of against
7 liabilities, judgments. cam and expenses which may in my way seems against said City
in consequence of th Ong of this permit.
APPLICANT U RSTANDS ANO WILL CO PLY WITH ALL N0 INT
SOUR ATIONS. /
Issued by: Date
Re-roofs
Type of Roof
Signature ol'AplilualinuContractor f Dow
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future building occupant store or handle huardous material
as defined by the Cupertino Municipal Code, Chapter 9. 12, and the Health and Safety
No. Section 25532(a)7
CYet 'lftt.'u
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 applicant or future building Occupant tax equipment or devices which
emit hannumm air contaminants as defined by the Bay Area Air Quality Management
all new materials for inspection.
District? y
0 Yes Nu
/News
I haw raaddeehe materials rcyvircmcnuunde,Chapter 6.95 ofuc Cilifar.
niaficahh&Safety ,Section 25505.25533 and 25534.1 umbmwad thatifft building
-
Joes nal carte ave a unenL Oat it is my mammal sty m notify the Occupant of the
m uiremc i muubcmetpriortu CcNtic mor Occup y.
Signature of Applicant Date
C I d
All roof coverings to be Class "B" or better
Ownararautho . gent