05110077 CITY OF CUPERTINO
BUILDING DIVISION PERMIT WNTRAcTQR INFORMyATION,
BUILDING ADDRESS: PERMIT NO.o 5110 0 7 7
10501 N TANTAU AVE
ER'S NAME: PERMIT ISSUE DATE
PACIFIC RESOURCES
7ARCHITECTIENGIN=E�:
NE: SANITARY NO. CONTROL NO.
BUILDINGPERMITINFOBLDG ELECTPLUMBMECH
t� 0 LICENSED CONTRACIOWS DECLARATION Job Description
1 bereby admin Wt 1 am licensed mon,provisions of Chapter 9(commencing
Scedon 70(111)orDivision 3 ofthe Busircv and oRaiom Code.and my license is
lraroeand �5]Q� REVISION--DOOR OPENING/ADD HARD CEILNG,
se, GtQ Lic.01
; comracmr RELOCATE PW STATION ADD JUNCTION BOX
ARCHITECTS DECLARATION NO NEW PERMIT ISSUED/ORIG. #05070067
31< 1 understand my plain shadlshall kW used in sec
public nNs
yU
c G Licensed Professional
OWNER-BUILDER DECLARATION
if 1 hereby affirm,that 1 am exempt from rho Contractams Lkamw Law for the
t
no following mason.(Section 103 L5,Business and Professlnn Code:Any city or county
5_ which acquires a permit to cmtsvuct alter,improve,demolish,or repair any structure
_iy priarmiaianwe,almroquime tWapplicanf for mchramer'tafticseLawlstatement -
go< NmWis ingwitpSeamt to tire provision of the eBusinssand cnxlaw(Chapter9 Sq.FL Floor Area Valuation
(commencing with Section 7000)of Division 3 o the Business and Profession Crede). hQ
_ that W u aneroid lhacfrom and the Ensu for the alleged exemption.Any violation or YY
Section 7031.5 by mry applicant for a permit subjects the applicanuo a civil penalty of APN Number Occupancy Type
not more than five hundred dollars(55001•
❑I.u owner of dm Property,or my emplaYcn with wages u dmir tele compensation,
wBlmthewmleandtheswctu.uwtinenxdornBctwrors (SM.7044,Buwas Required Inspections
and Proressian Code:TW Canuxmms License Law dw.+wt apply m e an owner of q P
progeny who builds orimpmves thereon,and who doessuch workh roulforthrough his
o amemploynes,provided that such improvements ice notinlW W or offered fnsa4 V.
however.the building or improvement is mid within arc year of amPledon,the owner- ,y
builder will have the burden of proving that W did nm Wild or improve far purpose of
,ale.). <v\
❑1.as twee of tW pec.704 .B sinessi and
connecting with IIRMedomnsecars - f�
convect d project(Sec.in a4,Business tad Profusion Ca dei TW Caouacbms and. V y.
ane oave des cot apply c an own.of psopeny+1m Wilds or 4.,invea conn.and. \�
who canuacss for such projects with a cannusar(s)licensed purwam m the Contruwri
Llecn n law.
❑lam exempt and.See ,BAPCfor this mown i
Dat
WORKERS COMPENSATION DECLARATION
I hereby affirm under parody of perjury ma ofma following declaratia¢
❑the m and will maintain a camuricaw of Content to self-inum re wolosescompen-
aded,sa provided far by Section 3700 of the Labor Code.for the perfoemawe of the
work for which this permit u know.
1 have and will maintain Wonaces Compensation Insurance,az required by Scctim
I of the Lawn Case.for the performance of the were for which this permit u issued '
Ware/t9Cyptpenadon innsuyaat_camier olio,Nq matter am'. I
Carrier.g{_lW�i VASI'.a i.. carrier
Pof Na.: L�
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(Thissecdmn wed not w completed i(de permit is format hundred doilua($10)
or less.)
I conify that in the performance of the work for which this Permit is issued.I shall me
employ any Person in any manner an as to become subject a the Workers'Compena0on
Laws of California.Due
Applicant
NOTICE TO APPLICANT:If,after making Nu Certificate of Exemption.you should
butane subject w the Woheh Compereadon pmvWom of the Labor Code,yen mats
rJ Z forthwith comply with such provisi."41 permit shall be dccmed revoked.
Z O CONSTRUCTION LENDING AGENCY
[-+ 4 1 Wroby affrmn that them is a construction lending agency for the performance of
D: > the wart for which Otis permit u named(Sec.7097,Co.C.)
6W.Q lender's Name
U O I certify that I law rod this application sed sac than the shove irdormatio t u
w~ cmraL I agree to counply With all city Nd county ordinances and state laws elating to
�U building construction,and hereby authorise representatives of Nu city to emmuprrn the
r shove-mentioned property for inpenion purines
E~ 4 (hoc) ree to ave,indemnify and keep hamsters the City of Cupertino against
� liabili' a falacnts and expenn which may In any way aamesgaint said City
U in co of granting of this P.mit.
^ APP U ERSTANDS AND WILL COMPLY WITH ALL NON-POINT Issued by: ' Date
SOU U no
sig f IicanU Dam
Re-roofs
HAZARDOZARDO US MATE RIALS DISCLOSURE Type of Roof
Will theapplisantno Muni building acupaptstoreorand the
Health and
as defwd by the Cupertino Municipal Code.Chapter 9.11,and tie HWth and Safety
Schen 1 13 111?1? All roofs shall be inspected prior to any roofing material being installed.
❑Yrs �o
W II taw aiplicant or future WiIJinY oavpant tax cyuipment or dcvicu which If a 's installed without first obtaining an inspection,I agree to remove
each hazardous air wart minants as&food by tW Bay Area Air Quality Management all erials for inspection.
District? ( �
❑Yrs Y.
Its. oasmamriats roquirurness oder Chame,6.95afthe Cables-
ria Hnith&S etion 15M.15577 soul 15574.1 undersand thmifthc Wilding
do.oras corm nn a dmt it is m 'Ininy m wdfy the pant of the
,equiremcntsw ich ho u o(a CcrtiOcam ofa
gnat e o 4pplicant Date
y All roof coverings to be Class"B"or better
Owner or mmamcd agcm arc' '