08050173 CITY OF CUPERTINO m - UnrRyw'�
BUILDING DIVISION PERMIT 4C,ONTRACT�,ORIIVQ,,,RMATIQN �,:
BUIL TNG ADDRE4 : PERMfT NO.
910370–X10380 TOWN CENTER LN GIDEL AND KOCAL 08050173
WR'S NAME: PERMIT ISSUE DATE
574 DIVISION ST 06/06/2008
PHONE: SANITARY NO. CONTROL NO.
ARCHITECUENGINEER: BUILDING PERMIT INFO
COMM' L TI RPLCMNT SUITE DRS& BLDG ELECT PLUMB MECH
O O O O
UOO LICENSED CONTRACTOR'S DECLARATION Fi�mst-•.JOb Description
iU F 1 baby affirm our 1 am licensed under provisions of Chapter 9(commencing ^•^--^ ^--T-- --- ^- ^-
`oj with Section 7")orDivision 3 of du Business soul Professions Code,and my licen¢is
rn in full farceand effect
jt22 Lice
rueC au I.ic.R
E,"O Dae Cthbsw.
ARCHITECrSOEC A b
� I u dcrsunJ my plans Nall be dud ss public mcnNo
5 U;
sQ: Licensed Pmfesaional
3 OWNER-BUILDER DECLARATION
.� F 1 therebytherebyaffum Nal I am exempt frommto Convector's Lee..law for the
p o fallowing meson(sccdan 7131.5,Business and Pcefcuiuns Code:Any city or county
$ which¢quires a permit to construct,Alcor,improtm,demolish,or¢pair any structure
iy prior N its issuance.Mau nerdics thC applicant for such permit to rile a signed sutemcm
sCNat he is liacved purmanuo the previsions of the Comracmr'o Ucome taw(chapter 9 Sq.Ft. Floor Area Valuation
k- (commencing with Section 7000)of Division 3 of the Business and Professions Codc)or
Nn he u e¢mpt rlreefrom and Ne basis for de alleged exemption.Any violation of
Section 7031.5 by any applicant for a permit subjects du applicant to a civil penalty of ane AAPN Number Occupancy
cot more than five hundred dollen(5500). p y Type
I,uownv of Ne pvquty,ar my wplowv with wage ssde'v an4 compewdnn,
antil
will do the won,and th The Contractors
is cot intended or offered farael apply n0an Basin of
pro ectywhiobu Code:The Comocton, rid who Law does ml apply lf an owner Required Inspections
own enywha Wilds 1 improvuch i m improvements
ts does such woeohisoffeced lwugh his
awn .ih,eea,p Wilding
or thatwch improwmenu in oat insended«offered for sok.H.
however.Ne Wil ding orimpromnenrishathwithinanewu o improve will have Ik burdm of Waving that W did err Wild«imprew r«pugett of
El I,as owner of the property sm exclusively contracting with liarded common m on
construct the project(Sec 7064.Business and Professiow Code:)The Cmmcmes U. .
cave law does not apply as an owner orpreperty who Wilds or improves Neuron.and.
whocunvects forsuch pmjeem with a conescraRs)licensed punuantW cite Comsacrofo
License law.
01.eaemps under See ,B&PC for thio reason
Date
WORKER'S COMPENSATION DECLARATION
I hareby affirm under penalty of perjury one of the following declarations
❑Ih:w and willmainuinaCcrufimuaf Coventbttlf-ivurtf«WorkersCpmpen-
sation,as provided for by section 3700 of the Lab«Code.for the performance of the
work r«whim this permit is knuc&
❑t have and will maintain Workers Compensation mmui a mquimd by Section
3700 of NC Lab«Code,for the performance ofthe won f«which Nis Ismailia humid. '
My Worker's Cnmpevauon lnsumn an. .and Policy number am:
Carrier.lL�/.y/��L kC.L�l�fA; Policy Na.:X13�
CERTIFICATE F EXEMPTION FROM ORKERIV S
COMPENSATION INSURANCE
flT a=flm need cot W cmopleed if Ne permit Is f«ane hundred dollars($100)
or less)
I certify 041 in the perfomiamc of the work for which Nis permit is handed,I shall oat
employ any person In my Moroccan as m become W bjeel to the WorkersCompCM1Ytim
Laws ar Ca ifomie.Date
Applicant
NOTICE TO APPLICANT:If,after making this Certificate of Exemption,you should
become subjm m the Wonefl Corewmation previsions of the Labor Cade you must .-
.J O forthwith comply with such provisions Or rm
Nis peit shall be deemed Mvoked.
'Z..'iCONSTRUCTION LENDING AGENCY
F 1hominy al0rm dor there is•consurwdrn lending agency for theIorfurmencc of
ho work for which Nis permit u domed(sec.3097,Cih,C.)
1 Q Lender's Name
Z)z Lenders Addmso -
U Q 1 certify that 1 have reed this application and sate that the aWw infomutian u
IL commeL I agree to comply with all CRY and county dNim saes and stem lawn mlaling to
building construction,and hereby wth«ice repodenuuves or this city in mitt upon do
shove-Menuaned prepcny for ivp,o uan ms which ms
(Wc)agree In save,indemnify and keep harmless the City of Cupertino agi imt
to in
equnce of themmindofpempermit may in any way stove abaivrseiOCity
V A PLICA nee of the granting of this permit ,r
�--� APPLICA U'DER ANDS AND WILL COMPLY WITH A11.NON-POINT Issued by: Date ((/.—
SOUR
Re-roofs
B' Lu pp i IrKour a
H RDOUS MATERIALS DISCLOSURE Type of Roof
Will the IPPRAMEorfuture Wilding occupemarem or; harudow maorial
Brod by the Cupenioo Muria Code.Chapter 9.12,ands the Health and Safety
.section 25532ra)'
❑Yu a All roofs shall be inspected prior to any roofing material being installed.
Will the applicant or comm Wilding occupant use composed,or deaee4 whichIf a roof is installed without first obtaining an inspection,I agree to remove
Ddu 'pannus air cmuminants as wilted by the Bay Ama Air Quality Managemcnl all new materials for inspection.
0 Yes j<
I have mad the haaamms maawrials mquimmenm under Chapmrb.95 of the Calif«-
niaH:aith&Safety Cade Sati«m25S05.25533mu125534.IMgcrsund their Nc Wilding
doe_not torten haw•anent that it u my ms mihilityw notify de oeeupml of the
regwomen nm eemapriarmissuwccoraccrrlcamaraIF� Signature of Applicant Date
er ulharired rot N.Wr All roof coverings to be Class'W'or better