04050014CITY OF CUPERTINO
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BUILDING DIVISION PERMIT
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ING ADDRESS:
DEVERA CONSTRUCTION INC.
PERMIT Ncb 4.050014
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R'S NAME:
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PERMIT ISSUE DAM
WOODMONT MANAGEMENT104
-0--COMMERCIAL ST qiTTIE
E:
SANITARY NO. CONTROL NO.
(408)441-9598
ARCHITEC rENGINEER:
BUILDING PERMITINFO
BLDG BLECI PLUMB MECH
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LICENSED CONTRACTOR'S DECLARATION
Job Description
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I hereby, affirm that 1 am licensed under provisions of Chapter 9 (emena ug
wiNSttdan7 )af Divislon3of Ne Businusan Frufe •ionsC de, arr-3' Iiceese la
m fullfarcea rm
REVISION --IN HOUSE USE ONLY
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License C Lic. M
Dam Qomuror
NO NEW PERMIT ISSUED/ORIG. #03110060
ARCH: A ON
L-Irrsundmyume.hall Iwusedas c.!Cds
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Licensed Professional
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OWNER -BUILDER DECLARATION
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1 .('firm I am exempt Item the Canuacm License Law for the
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Code: Any city
following moron. on 703 1.3, Business and o
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cnnawct, alma impmw, demolish, ri repair svuctum
arch t w, demolish, structure
which requires; permit
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Nose Lawdstammem
issuance. re ed
the
thiormiu ensedpalmmquithe Nevisios of forMe sucContractor's
that wit pursuant
Sq. Ft. Floor Area
Valuation $0
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70th) of Division 3 nd Professions Code) of
me cing the Code) or
Nat he 6 sump( thdmfrom and Ne Eesti for Ne alleged exemption. Any violation of
that he is exempt Meadows and M Division r M the Business and on. Any
Section 7031.5 by Any apPlicant fon permit subjects Ne applicant an a civil penalty of
APN Number
Occupancy e
P Y �'P
not mom Nan five hundred dollars ($500).
32609064.00
❑Les owner of Ne pmpdtty, or my employees wlN wagmulMir sole compensation,
willdo Ne work and Neawc(me is not intended orarfercd forsale (Sec. 70". Business
Required Inspections
And Pmfessioru Conic: The Conuacmrs License Law docs not apply the an owner of
property who bu ilds or i mproves demote,ern, and who does such work himself or through his
awn employees, provided Nat such improvements; are notimmoded arra Bred forsale. If,
.
however, Ne building or improvement Is sold within one year of completion, Ne owner.
builder will have 0e burden of proving that he did not build or Improve for purpose of
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sale.).
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❑1,ruowner ofthe contracting with clashedommracmrs to
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csproperty,amainesi and
came La d project (Sec. o an Business and Professions Code:) Theves twelor's Li.
cense Law dors not apply an owner of property who builds or improves thereon. end,
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whocontracts for such projetts with a con(nc(or(a) licensed pursuant m the Connector's
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License Lew.
I am exempt under See. . B & P C for Ni. myon
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WORKER'S COMPENSATION DECLARATION
I hereby affirm under penalty of perjury one of the following declarations:
I hese and will maintain a Canificam of Consent to =If -Inure for Workers Compere
smion, as provided for by Section 37011 of Ne labor Code, for the performance of the
work for which this permit is issued.
0 1 haw and will maintain Workers Compensation Insurer=, as required by Section
3700 of Ne Labor Code. for Ne performance of Ne work for which Nis permit is issued.
My We omp nseuonl nntt nicr end PyonumfM am:
ayR3gr Polity No.ieWORK�1%L�.[.�L
C/ TIFICATfi OX PILON FROM WORKRS'
COMPENSATION INSURANCE
.
Thisa=tion need noted completed If (he Permit is for one hundred dollars ($100)
or less.)
I certify that in the performance of Ne work for which this permit is issued, I shall not
employ any Person In any mmncrso as 0 became subject to NC Walkers Compereadoa
Laws of California, Date
Applicant
NOTICE TO APPLICANT. IL after making this Certificate of Exemption, you should
become subject to Mac Worker's Compensation provisions of Ne Inbar Codc, you must
Oforthwith
comply with such provisions or Nie fermi( shall be dccmad revoked.
LENDING AGENCY
r~N.CONSTRUCTION
7
1 hereby. iren Nat Nem iso consuunlon lending agency for Ne performance of
the work fol which this permit is issued (Sec. 3097, Civ. C.)
Name
QLenders
Landers Address
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I certify that I haw read this application and sham that the show information is
Fcorrect
I agree lo comply with all city and county on inmem and amt: laws mixing to
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building construction, and hereby auNoriae representatives of Nis city to enter upon Ne
shove-memianed Property for inspection purposes.
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(We) agme to saw, indemnify and kap harmless the City of Cupertino against
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limilides, judgmcnu, curls and expenses which may in my way acme against mid City
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in consequence of the Implies of this Permit.
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APPLICANT UNDERSTANDS AN I COMPLY WITH AL N -POINT
Issued by: Date
SOURCER L NS.
Re -roofs
:
n rco pelican Dove peer
HAZARDOUS MATERIALS DISCLOSURE
Type of Roof
Will the applicant m future building occupant store orhandlc haaar lows matenal
efrned by tier Cupertino Municipal Code, Chapter 9.12, and the Health and Safety
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All roofs shall he inspected prior to any roofing material being installed.
❑ Y �ftu
Will the applicant o fuWrc handing occapxnt use equipment or devices which
mit havardaus air conmminanu as defined by be, Bay Arca Air Quality Management
- If a roof is installed without first obtaining an inspection, I agree to remove
all new materials for inspection.
District?
❑Yes 711n
l have mad the hvardo , materials rcquimmenu under Chapmr A95o(Ne Celifor
nla Hmlth&SafctyCodc, Sam. 25505,25533 And 25534.1 understand thatifthe building
'
Joel not currently have a mnent Nat it is my res mihilily m notify tier ecu t of the
mquircmcma which est tact pdoloi : r. Care ofa=an
Signature of Applicant Date
owns authommdagen, ate