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CITY OF CUPERTINO
CUNTRe1CTORINF®RMAT Old
BUILDING DIVISION PERMIT
BUILDING ADDRESS:
A&A REGRIGERATION CONTRACT
PRSTNo.04050175
OWNER'S NAME:
MENLO EQUITIES
D4c)NTgRrY HIGHWAY,
PERMfTfSUEDATE
E:
5 ITARY I qg*OL NO.
ARCHITECT/ENGINEER:
BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
0 0 0 0
LICENSED CONTRACTOR'S DECLARATION
Job Description
o
I hereby afilon Nal l son liesnsed underprovisions of provisioof Chapin 9 (c mmeneing
N t1 7IXX3 of Divimx.3ofthc Bu Pro ns jutdm Iicenmu
infool and ,_ n
`r_
I I
EN ABOVE, OOF
Dam Contractor `
t,SC i
ARCHITECTS -p LAR0 1 1, 1•
cratsnd my shall he usediakPu niNf\
i ,.j
plain
Licensed Pmfessiontl 1 _a
OWNER -BUILDER' ELLUPATION
I\�l'
I botchy affirm that I am excmpl fir UW Cnnuecb/a ceae aw for the
(allowing reason. (Secuun 7031.5, Business Q pmfcuiuniv d,aL.) �or county
which mgnlfc. a pemdt m Cnn3lnlCl, OhCf, I m: Il er m r any atmetum
Poor le its iuuencn, aim requires Ihe,pplicaOr 1 to Ne asigned statement
Sq. Ft. Floor Area
Valuation
that he i3 licensed Purmml to We provisions of the CORMON'S Lemom Law (Chapter 9
(commencing with Section 7") of Division 3 of the Business and Professions Code) OF
that he Is exempt themfrom and We basis for the alleged exemption. Any violation of
APN Number
Occupancy Type
Section 7031.5 by any applicant for a permit subjects the applicant to a civil penally of
.or more than five hundred dollar. ($500).
v
❑ I,uawnuof0cpmpmy,ormyemplayceswimwagnu111eir MICCMPenadon,
- 00 Required Inspections
will do the work, and mealructure is not intended oro@red farum(Sec. 7044, Business4
and profession, Code: The Conummfs License Taw des osnot apply W an owner of
prop ar who bulldsor improves thereon. and who dmsauch workhimself or through his
y
own employees, provided that such improvements are, not intended oroRered for sets. If,
however. the building or improvement is mid within one year of completion, the owner.
Wilde'will have the buNea of proving than he did not build at Improve for purpose of
sale.)
❑ 1, as owner of the progeny, am exclusively convecting wit licensed manuacters to
construct We projec7 (Sec. 70,14, Business and professions Coda:) The ConuacmrS Li-
cence law does not apply can owner or property who builds or improves Bremen, and
who common for such projects with ammutetor(s) licensed punusnt to die Corw moves
License law.
❑ I am exempt under See . B k P C for moa mann
Owner Date
WORKER'S COMPENSATION DECLARATION
1 hereby n(0rm under Nulty of perjury one of We following declefNon:
.ve and will maintain a Certificate of Consent an self-Imum for Wmian's Compen-
on, u provlded for by Section 3700 of We 1a1W, Code, for the perfamnance of We
wefor which this permit is issued. '
❑ 1 have and will maintain Worker's Compensation Insurance, as inquired by Section
3700 of the labor Code, for the performance of the work forwhich this permit is Issued.
My Workers Came naponlnsurm¢amuand Poliymentc,me:
q
Ca 'u ! tflA Policy No.: _4)w D / a2,P
.
CERTIFICATEOFEXEM ON FRQM WORKERS'
COM )N NCE/+vj /-0_
PENSATIO
(This scedon need not uncompleted If the permit is Imonc huAFJrcd dollars (SIM)
nr bsa)
1 arBfy mat in We performance of We weals for which this Permit is issued, 10411 nm
,
employ any - corn In any manner an as to become subject W the WorkedComp radon
Laws of California. Data
Applicant
NOTICE TO APPLICANT: If. after making this Certificate of Exemption. you should
become Subject W We Workui CompcasW on provisions of We Lahm Crede, you most
forthwith comply with such provision or this Permit shall be damN revoked.
CONSTRUCTION LENDING AGENCY
I hereby affirm that mem is a construction lending agency I'or We Performance of
the wools (Lir which this permit is issued (Sec. 3097, Co. Q
L,ndces Name
Lcndefs Add=
I certify that 1 have rad this application and soon that the above information is
correct. I goes to comply with all city and county ordinances and soon, laws relating to
building construction, and hereby amhodxe representatives of this city W enter upon the
.hove -mentioned property for inspection purposes
1
(We) agree W Live, indemnify and keep toothless the City of Cupertino against
labllhinjudi ments.co34 and expenses which may In my way accrue agalnl said City
in Commq a of th granting of Nis permit.
APPLIC UI D.RSTANDS AND WILL COMPLY WITH ALL NON -POINT
Issued by: Date
SOURC b ONS.
Z` -c tf
Re -roofs
Type of Roof
s' o p IcanUCanuml r Dam
HAZARD S MATERIALS DIS RE
Will thcapplicanlurfulu buildingoccupamsoMontsndlc huarcous mabool
as dented by the Cupenmo Municipal Code. Chapter 9. 13, and the Health and Safely
Code. Secuot 35533(a)?
All roofs shall be inspectede nor to any roofing material being installed.
N
If a roof is installed without first obtaining an inspection, I agree to remove
Will the applicant On future building occupant use equipment or device, which
huoordous air conumin.nv defined by the Bay Area Air Quality Management
all new materials for inspection.
In,,?
❑Yin No
thew read theWaNlm3mamrlaLs quimmcntsmd rCMpbr6.95o(the
daHeal"safcty Ca .Sayan n505.35533 andnSM.I undcrmm irft ilding
date not cu y m . mnanc mu of u my re3pmmihilily W notify ds asupant of me
requtremen allW met poor Wissuance ofaCemuricateofOccupancy,Signature
�'Ap licant Date
al
A I roof coverings to be Class "B" or better
Owner mf aeved agent Dab