05030116 CITY OF CUPERTINO *,3�' a5-*� z
BUILDING DIVISION PERMITCU1vTRk1CTURINFORMA ION:
BUILDING ADDRESS: PERMIT NO.0 5030116
ER'
02/23/2006
P NE: SANITARY NO. CONTROL NO.
ARCHITECT/ENGINEER: BUILDING PERMIT INFO
BLDG EIFCT PLUMB MECH
Z
30p LICENSED CONTRACTOR'S DECLARATION Job Descri tion
1 hereby affirm that 1 w licensed under previsions of Chapter 9(commencing P
with Section 7001)of Division J of the Business and Professions Coda,and my license is
n inrulfmeeandeffect. CONDO-2 STORY (2 , 5901 LIVING)
License Clue Lk.0 NEW ADDR WILL BE ASSIGN ON WILDFLOWER WAY
FFFgF— Dalc Confiner
ARCHITECTS DECLARATION
1 understand my pians Mall he used as public records
i5 Licensed Professional
O OW NEABR DECLARATION
I herchy.(fere 1 .exempt from the Contractor's nu law for the
0 following mean.(Section 7031.5,1.d,Business Pmfnssiou Code:Any
oily w manly
$�
which m9uima•Permit to eoruuuct.aloe improv.demmllab,or repair any structure
Prior m its issunm.also requemes the applicant rwauh permit to file arsnedar9kmenm
�< That he is licensed pursuant to the provisions of the Conuacar's License law(Chapur9 Sq.Ft. Floor Area Valuation
(commencing with Sectlan 700)of Division J of the Business and Professions Cole)or $310800
$ dust he Is exempt therefrom and the hills for the alleged exemption.Any violation of
Section 7011.5 by any applicant for a permit abjecu.the applicant to a civil penally of APN Number Occupancy Type
not mart thus R.hundred dollar($500). .
❑1.umnuofthepmprny,mmyemploymwkhwresudekmkcompewdm.
80
willdadwwork,and NeauuwumkmlinundedaraBemdfw We(Su.70N,Basimas Re aired Inspections
and Prolcau mu Cade:The Cemeteries License law dm not apply w an owner of q P
propeny who builds or improve thereon,and who does to h work himself or through his
own employces,provided that such improvements am nminunded aroQeed forests.IL
j
r,Ne buWin'or impovement la sold within one year of completion,the owner-wiB havethe burdan ofproving Wthe did notbuildorimprove Irepurypse of owner of ct Sec.? .am a Business
aid ceftemkns with li Th ed coetrutnn l-
wme,La the pmkn apply
0 in mmer of rop Profeaalo l Cadei Theves humor,1.i-
who law dmnot epPIYamawnsofproperrs)limbuildsfir,""QI humor,
whence cu fonts[h DrojeN with acantnemr(A)lammed punum110 Contracm
License
❑tem tunOerS .Bk Carr th�n
Dak
COM TION DECLARATION
I hereby AMorebn r DuWlY of perjury ane of the following dularuianc
❑1 ham and will maintain a Cu00coa or Consentueself-Inane far Wmker'a Compere
cation,as provided for by Section 17M of the labor Cade,for the performance of the
work for which this permit is!used.
❑1 haw and will exhume Worker's Compensation Iwrance.as required by Section
170Daf the labor Code,for the pe formanmof the w•wk for which Wes permit is iwoed.
My Worker's Commutation Insurance eamri and Policy number art: '
Carrier: Policy No.:
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE ,
Ohlorectlm need mtbecomplewd lithe permit is foram hundm idallm(SIM)
or lila)
1 cenir,that en the performance or 0 rk for w ich t is Permit Is issued.l shall not
cmployanypermn Rnym
Applicant
NOTICE It AP 1 IT. r m n Ce ificate M Exemption,you Would
rna
become mbjen a orker'a Peon u of the labor Cod[,you must
O foMwith comply with such pmvisi es w Wu permit shill he rimmed revised.cerevised.z(Al CONSTRUCTION LENDING AGENCY
[r Thereby affrm that them Is cautmctlm lending gency for the performance M
13i > the work for which this permit is issued(Sec.3097,Clv.C.)
W QLender's Name
0. lenders Address
U0 1 certify that I haw and this application end sum that the&bow information is
It, coma 1 agree a comply with N city and county oNinames and slow lam mWing te
OU Wilding construction,and hembyauthodm mprcsenutiws of this city lm enter upon the
U above-memiuned Property for iMPeNon Pugmsea
(We)agree to sew,indemnify and keep batteries,the City of Cupcoina 198104y Iiablletl ,judgmonlo,coms sed expenses which may in any way accrue against saidCi
U 7 in ca ranee of the wanting of this permit.
APP I A UNDERSEA D A D WILL COMPLY WITH L NON-POI Issued by: DateZ
SO
Dak
N ARDOUS MATERIALS DISCLOSURE Type of Roof
WIII IhC applica 110,forma aidingo' toom orhmdlehuardoes material
u defend by dee Cupeeino Mum pal Cade.CWpwr 9.13.and the Health and Safety
.&Nm DYea 2.551200? All roofs shall be inspected prior to any roofing material being installed.
o
Will the"Pliant or rumne ildeng occupant ase equipment w device which If a roof is installed without first obtaining an inspection,I agree to remove
emit bumptious air contaminants u cfned by the Bay Area Air Quality Management all new materials for inspection.
District?
❑Yu
ow read the buaN xenalseum murder Chomer A95 of the Califor.
ria I @Salely Gnde.Sections25 5 2551&.10 dersund ifdw but ng
D, All roof coverings to be Class"B"or better c/