050700860 E
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CITY OFCUPERTINO
BUILDING DIVISION T��,��
PERMIT
COtOAR,\flNitAC+1 Q1tINORVYlAION:
BUILDING ADDRESS:
DE ANZA PROPERTIES
PERMIT N90 5 07 0 0 8 6
10100 TOR E AV
OWNER'S NAME:
PERMIT ISSUE DATE
DE ANZA PROPERTIES
005
g;
SANITARY NO. CONTROL NO.
ARCHITECTIENGINEER:
BUILDING PERMIT INFO
ELECT pLO MECH
0 O
LICENSED CONTRACTOR'S DECLARATION
Job Description
1 hereby affirm the,) am licensed under provision of Chapter 9 (commencing
p
with Section 70D0) of Division 3 of the BusioessaM Professiva Code. and my license is
In Om to. and effect
REPAIR LANDING & LIGHTING
License ClassLic.0
Data Contractor
BREEZEWAYS 2 FLOORS
ARCHITECT'S DECLARATION
[Understand my plana shill he used as public record
Licensed Professionsi
OWNER.BUILDER DECLARATION
I hereby affirm that I am ucmpt from the CommcuYs License Law for iW
following mason. (Section 7031.5. Business and Professions Code: Any city or county
which requims • permit in canwuct, alter. improve. demolish. or repair any structure
pow to its Issuance. also requires HM applicant for inch permit to rile a signed Wlamen
Be, Condacuri Uccnse Law (Chapter 9
Sq. Ft. Floor Area
.A r_
Valt$aga�mo 00
Nam be 4liicensed Premum to provision, of the
(comm, eringwithS don700D)n(Division3orthe Busies .ndPmfetsiom Code)o
that he 1. exempt doormat and the basis for the alleged aaemption. My violation of
APN Number
Occupancy Type
Section 7031.5 by airy applknal for a permit subjects the applicants in civil penalty of
not mom than five hundred dollars (M).
36902032.00
u owner of the propmy o my employees with wages is their sole compenuHon,
Required Inspections
will do the work and she structure is not intended or offered run Me(See7041• Business
ane Professions Cade: The Communes License Law does out apply in an owner of
q p
property who buildorlmproves Neem. adwW doessuch with: himselror through his
awn employees. provided that such improw:ments am not Intended aroQeed for sada If.
however. the Wilding or improvement is into within on year of completion, the owner•
Wilder will ban the burden of proving that M did not build or Improve far puryom of
sale.).
❑ I, is owner of der property, am exclusively conducting with licensed condacurs to
construct the pm ect (Sec. 7014. Business and Profession Code:) Ther Conwcm's U.
cense Law does not apply m an owner of property who Wilds or improm thmeon, and
who contracts for ouch protects with acanuacror(1) licensed pursuant so Use Communes
License law.
❑lam nem µMer a .B&PCwthis.
Ow Dan
W SCOMPENSATION DECLARATION
I hereby oder penalty or perjury oro of the following declamma:
❑Ihaveandw mainuinaCoNfieste orfComm�uaselr4nmrtfoWorter'aCompen-
aanon. at provided for by Seeman 3700 of the labor Cade. four tW partum om of the
.it for which this permit is When.
❑ 1 have and will mahout. Workers Compensation Insu , as required by Soman
37W of the labor Code, for the performance of du went for which this poem, 4 issued.
My Workers Compewdon lamunm carrier ad Polity number are:
Cartier. (Alis r17
Policy No.:
GERTI TE 6 E%EMP I0N PR0M WOR S'
COMPENSATION INSURANCE
(This smllon need not be completed If the permit is for ane hundred dollars ($101)
or lea.)
I certify that In the performance of the wad for which this permit 4 issued, I Nall no
employ any person in my manor an m in become subject in tM Workers' Compensation
Laws art California Dau
Alrylkal
NOTICE TO APPLICANT: If, after making this Ccnlfiovte of Exemption, you should
become subject in the Workers Compensation provisions of Ne LAWT Code, you mute
roMwith comply with inch provisions or this permit shall be deemed ranked.
CONSTRUCTION LENDING AGENCY
1 hereby affirm that Herz 4 a construction lending agency for the performance of
Use wad for which this permit filum u (See. 3097, Civ. C.)
'
Lenders Name
Lcod es AM.
I cmify that 1 ban read this application and sum the the amove information is
"
CmeneL I agree to comply with all city and county ordinances and sun laws ralnling to
Wilding convection, and hereby madman representatives of this city to enter upon du
a Wve-mentioned property for Inspection purposes.
(We) ague 10 save, indemnify and keep humblest the City of Cupertino against
Ilabilides, judgbenes, coves and captain, which may In my way accrm agalm, aid City
Inconsequence of the granting of this permit.
APPLICANT UNDERSTAND IU. COMPLY ALL NON -POINT
Issued by:S4tQ�t&w Date
SOUR
Re -roofs
Type of Roof
Jilliliones,afAan omrmbr Date
HAZARDOUS MATERIALS DISCLOSURE
Will plicator future building occupanawm or handle haardous maudal
u dcflxd y Cupertino Municipal Code. Chapter 9.12. and the Health and Safety
Cad. Sa 25532(1)7
All roofs shall be inspected prior to any roofing material being installed.
u _&kNo
If a roof is installed without first obtaining an inspection, I agree to remove
Will the applicant or future Wilding occupant um equipment or dcvim which
II haamoov air contaminants as defined by ther Bay Area Air Quality Management
all new materials for inspection.
Dimict7
❑Yes
I have mad the haardms mmrialsaquiremenu underChamor6.95 of the Califor.
nia Health& SafelyCade, Sections 25505.35533 md25534, I undersand the iftha Wilding
dna not c ave a mman4 N ponsiNlh tha occupant or du
reqs en tai be dorm' mor. 0 cvpmcy,
Signature of Applicant Date
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All roof coverings to be Class 'B" or better
Owner o cot dagam Date
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