06080061 CITY OF CUPERTINO /-. »mk��/^` I�T�+
BUILDING DIVISION PERMIT CONTRAC'A Rlull•URMATION
BUILDING ADDRESS: CHARLES PANKOW BUILDERS La
AERMIT N0.06080061
10101 N WOLFE RD
ER'S NAME: PERMIT ISSUE DATE
SEARS ROEBUCK AND CO 2101 WEBSTER
PFIONE:
SANITARY NO. CONTROL NO.
(510) 893-5170
ARCHITECT/ENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
lop LICENSED CONTRACTOR'S DECLARATION Job Descriptionw❑ I hereby affirm that 1 w licensed under previsions of Chapter 9(am
mencin{
iW wiNSecdon7gN)af Division Jafthe Businev and l'rofessinm Code,and my license is
!�N in full face and effec
;l2c Dak�Cion;1 1 x5a� 3LS' REVISION TO STRUCTURAL DETAIL PAGE S1 . 0
ORIG PERMIT #06070150-NO NEW PERMIT
I ARCHITECTS DECLARATION /
a 1 undcrmanE my pans shall be used as public me.,&
yV
G y Licensed Pmfcstional
OWNER-BUILDER DECLARATION
i O y 1r hereby.Rath mm I am.Bump,(rum the Contras Ca License Law far de
:OC o (allowing reason.(Section 9.natru Business and are.dcoom Cale:Any city as aunty
$�i which its mu.permit requires the alkcimparvc,h Permit, fie a sig anyswment
z< prior Or ill issuaac,also requires the aite.o for such permit m Glc a signal statement
tsp that he a licensed pursuant tothcprovisiomofineConuacmhLicehselawlChaptn9 Sq.Ft. Floor Area Vall3attq�000
21-C
� (commencing with Section 7000)of Division J of the Busincas and Professions COJc)tar
-�.. diel he is exempt therefrom and the basis for the alleged wroad.n.Any vlolalio.of
Section 7071.5 by arty applicant for a panni,subjects the applicant W a civil penalty of APN Number Occupancy Type
not mote man GK hundred dollars(M). 31620080 . 00
P y YP
❑1,u owtw of IW gvpeny,a mY emploYces with wage ss they sole campewtion,
will not the walk.and then .isnot muendod Or Olfmcl formic(Sce.7044,Bradrcat Required Inspections
and Paofessure"Cod'.The Convxmfs License law does not apply m an owner of q P
property who builds ar improves daemon,and who doessuch work himse:forthmugh his
own employees,provided that such imphommau am not intended oronmcd forsak.If.
homwer.the building or improvencnt is mid within one year of completion,the owner-
builder will have the burden of provihi Nat he did Imt Wild ar improve for purpose of C
sale.),
❑1,construct owner of ct ac.704•.Bead ss and confessions Cid:)Thud ahuacmrs I. \ a�
eroeLatheprojesi(Sec.70 a amen of and Professions Code:)Them;doermrs n V
w ose law doss not apply je an owns of property who Wilds or improves Noncan,and
whocontractsLace for such projects with a rnnuxba(s)licensed pursuant m fk Canveclufs C
License Law. �J
❑lam exempt under Sec. .B&PC for Nu mason v
Date
WORKER'S COMPENSA770N DECLARATION
I thereby affmm under penalty of perjury one of Ne fallowing declarations:
❑I hate and will maintain a Certificate of Consent k self insure for Workers Compere
section,as provided for by Section 3700 of the labor Cade,for the pearman.of the,
work for which this permit is issued.
❑1 have and will maintain Workers Compensation Insurance,as neyuimd by Section
3700 of the labor Code,fur the pearmarance of the work for which this permit u issued.
My WorWe fiiy�I...came,and Polity number a/a3:/s,.y
Cartier. acT Policy No.:} 7 Z
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(Ihu section need not W completed if de permit is fortune hundred dollars(SIM)
or less)
I ccnify that in are performance of the work for which this permit is issued,I shall nm
employ any person in my mouser an as no become subject to f Workeai Compensation
Lam of California.Date ,
Applicant
NOTICE TO APPLICANT:IL after making this Certificate of Exemption,you should
becameaulaim On,the Workers Compewtion provisions of the,La Wr Code,you am
.J O forthwith comply with such partitions or mos permit shall W dmmed rowled.
zy CONSfRUCr10N LENDING AGENCY
'r+"• I hereby affirm Nat dere iso contraction leadingaitecy for the per(oamaaec of
LY. 7 the work for which Nis permit is issued(Sec.3097,Civ,C.)
6W. A Leonora Name
= z Lendces Address
U C I ccnify that 1 have read W s application and sac that the above infatmadun is
ly F correct.I agmc to comply with all city and county ordinances and sum laws relating m
building eanstauction,and hereby auNodm maesemmives of this clay to enter upon the
U
ahbvc-mentionedpmpeny fur inspection expenses
pamp.which s.
(We)agree to save,indemnify ad keep harmless the City of CmPefhna asaiest
03 N Iiabu.sequenea o nu,casss o,.(this
which may in any way acemc againstsaid Ciry
t.)Z, in eonsryuenec of the iruting of Nis permit.
^ APPLryII ANT UNDERSTANDS AND WILL COMPLY WITH ALL qON-Py NT Issued by: Date �- �—a
�5 —fes � d/3s/ 6 Re-roofs
Si Protons of Ap t UConurmw, r" Deck
HAZARDOUS MATERIALS DISCLOSURE Type Of Roof
Will the applicant or future Wilding occupant mom or handle hanrdou humeri
as&food by the Cupedim.Municipal Code.Chapter 9.12,and Ne Health and Safely
.So,tim 25532(4)7 All roofs shall be inspected prior to an roofing material being
C]Y. pyo P P Y S g installed.
If a roof is installed without first obtainingan inspection,I agree to remove
Will lW applicant or rum Wildini accupam use equipment alkvicea which P $
emit h tcardous air conumimnts as defined by Ne Bay Area Air Quality Management all new materials for inspection.
District'
C]Yes 'IRy
I have mad me Itcoudms materials na"marocna under Chapter 6.95 Otto,Califon
nia health k Safety Cade,Secdmu 25505.25533 and 25534.1 undersand that if de Wilding
Jars Currently have a WI it u my mapomibility m notify de aceepam de
m enawhic me rmlas aIacndfeakor r. SSlgnatureofApplicant Date
H
ncr tar mdm dagen, D,m - All roof coverings to be Class "B" or better