05030115 CITY OF CUPERTINO k ry�r. +y.��. 'y� pis /�'� *7 ,r'
BUILDING DIVISION �Vt\a1lu&MR4140A1YlA.l^TIIN
PERMIT •� , . . �r,.,t ,ah��,a€�'�•1�. � �, �,.�� �,�
BUILDING ADDRESS: APPLIED CONSTRUCTION TECH PERMIT N005030115
gn
HR'S NAME: PERMITL4UEDATO
CUPERTINO FIN -
NE: SANRARY N0. CONTROL NO.
(408) 252-9990
ARCHITECTIENGINEER: BUILDING PERMITINFO
BLDG ELECT PLUMB MECH
�CLICENSED CONTRACTOR'S DECLARATION O
1 hereby affirm,that 1 an Ims ssed under Provisions of Chapter 9(commencing Job Description
INch
Son 7000)of Division 3 ofNc Beat.awl Profession Cade,and my license is"Innfo�arymdeRect1p/�2� TENANT IMPROVEMENT-INTERIOR
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Dem Conlracbr ��ww�� ""
ARCHITECT'S DECLAR ON .L(V l QiA�y
V VV
'� I undcrsund my plan alull W mud u public mnWa �' p�p p�
50�� 'nV7• L�rLm
a Licensed Professional
+� 3 Oat I am eUIIDER DECLARATION Comment's
E I hominy a(Em mel 1 1. exempt form the Caeoabnr'.License Law for aW
O O following mason.(Saito 7031.5,Badness and Rofesalan Cade:Any city or county
$ which nqulrts a permit re ennWnet,alcor.Wprow,dt,ermitt fi mpalr any ammum --
'^
prior un incensedIssuance.
purse mgoiw red applicant for nbM1ractue ra Tensele a Law
auumem
the,(commencing
ssN pursuant tomanprovisions o(Ne Conuacw/a Lkenu law(Gupter9 Sq.Ft. Floor Area Valuation
that he s emnapN Section700Mand the
buts n 3for of the Business and onfMy vi Code)or
.. Sear Session
k exempt therefrom and the bur it the Subjects
the
exemption.to Any l penalty
of
not on 7031.5 live
any red doll rte•permit object 0e,applicant m a civil penury of a ecupaney Type
not mom Nan Ove 6unAmd dollars(5300).
❑1,As owner of 0m property,or my employees with wages as their sole eampensa0oe,
will do 0m wink.end 0 emnanuse B not intended oraaered forsake(Sec.70th.Business
and Profession Code:The Gm m nes License law dos amt apply m An owner of Required Inspections
property who builds or ire prom daemonand who does such work himsel f ar through his
own empkyw,provided that such improvements ale not mmnded oroRered fors0c.If.
however,the buildingar improvement is sold within one year ofnmpledon,the owner.
builder will have the burden of proving that he did not Wild or improve for purpose of
ilk.).
❑1.as owner of 0m property.am exclusively contracting with licensed ontrumn to
construct the Inject(Sec.7014,Busine.s and Prolesalans Cade:)The Gnuacmrs U.
ewe law don not apply As N owner of property who Wllda or impmwa Nemon,ad
who convect far such prejeen with a commensals)licensed pursuant no the Canuumes
License Law.
0 tAn,esmept under See .B Q PC for Ni.won
a Dam
WORKER'S COMPENSA71ON DECLARATION
I Mmby eRlrm under penalty of perjury one of the fallowing declaration:
7307.00
b•ve and will meinain aCeNficam of Consent m selGlmum fur WorkersCwnpem
.u provided fur by Satan 37(10 of the labor Cede,fur the performance of de,
for which IAu permit is issued.
I
have ad will mainWn Worker's Compensation Intwmm,u required by Section
ofNe LaborCode,for Ne performance ofthe work for which Nis permitisissued.
Wart a Compessatjon lase, nuc canf�jand Policy montheram:on e�'tYll71(�icy No.:J
CERTIFICATE OF EXEMP170N FROM WORKERS'
COMPENSATION INSURANCE
Chis section need not W completed If Ne permit is forest,hundred dollars(SIM)
or leu.)
1 unify that in 0te performance of 0m work fur which this permit is lased,I Nall not
employ any person in any manner an As In become subject to IN Workers'Compcssalon
Laws of California.Dam
Applicant
NOTICE TO APPLICANT:If.After mating this Certificate of Ememprion,you should
become subject m the Workers Compessadon positions of the labor Code,you must
.,O forthwith comply with such provisions or this Permit shall he teemed masked.
z 0 CONSTRUCTION LENDING AGENCY
(n52 I hereby afOm that them It a commission lending agency for the Performance of
ai t7 the work for which this permit is luted(gal.3097,Civ.C.)
0WQ Lenders Name
z Lender.Addrtss
O Q I certify that 1 have rtW this application and some the the above Information k
F bonen 1 green amply with all city and county ordinances and sues lenss miming;en G
7 rJ Wilding conawcuon.and Wrtby authorim rtpresenutiw of this city meaner upon the
W Al ovementianed properly for inspection purposes.
G (We)agree to sew.Indemnify and keep humkss the City of Cupertino sgalnu �—
wyh Ilabilimes,judgments,coed and expenses which may in any way some.Sant said City
U 4 Incon¢q ofthe taming of thi permit. 1 J w
APPLI LAND AN ND W COMPLY WITH ALL NP01 Issued by: Date V
SOU ER U 0
Re-roofs
Signaurt Appi on m Dam
HAZARDOUS MATERIALS DISCLOSURE Type of Roof
U_
applicm,w future building occupant alone or handle ha rdous maudal
As 111 by 0t,CupeNno Mord.
Code.Gapmr 9.12,and the Health and Suety
Section 25532(.)7 All roofs shall be inspected prior to any roofing material being installed.
Ye.
Will ht,applicant o fumm Wading occupant sea equipment or devise which If a roof is installed without first obtaining an inspection,I agree to remove
emir haurdous air conmminana As defined by the Bay Area Air Quality Management all new materials for inspection.
District? /� '
❑Yes ,[Jqu J
IhrvcmWtpe haadn mucaalsmyuiremcnu under Chapur 6.95 of the lifw.
nit Hes Mail (pdc. 503.23 3aaW755.le.l undcuwdlhsHfda ilding
dao t urtenll apse r It u rtspossihility te notify aM atop r of Ne
req rt naw ten tel en r. rm.marmnpenby •gnatureofApplicant Date
Dome rnthatlyedagent m All roof coverings to be Class"B"or better