01020065 CITY OF CUPERTINO
BUILDING DIVISION PERMIT CONTRACTOR INFORMATION:
BUILDING ADDRESS'. PERMIT NO.
065
(OWNER'S NAN :: -3 Ifil WBEFE RE) AwLicxTboN SUIT DATE
='/14/2001
•PHONEWE AND PROzTE6TS P4 V SANITARY NO. CONTROL NO,
n ac Z ARCHI'IEC1'IENGINIiI?R: BUILDING PERMIT INFO
u❑ BLDG ELECT PLUMB MI!CH
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LICENSED Iam remold
ACTUR'S wki I,RATIUN Job Description
25. m=pQ 1 hereby odimn Incl 1:nn of lac II nnJa Prov i.inns of Chapter,Cod . tcnmmeneing
<� with ti ll for eland of Div un 9 of the Buxincxx and Pmfcssiun.CnJu.unJ my lhcnsc
y^-� IS In full force al cBecbi,i
Asa I:ate chase Lic.M TEMPORARY BUILDING
3 0 Lane ARCHI I'IiCT31UfCLANAI'ION FINALE D
I undva,mim my [..,,hall he mod as public records
d 25p 1p Licensed post e..tonal
ac°,
OWNER-BUILDERDECLARATION MAY 1 0 2001
u7 of I hmehy:Jlinn'bar 1 am esear,fnnn the Commcfa,',License Law En Ian
F_ following reason.(Semens 91131.5.Ifmsine,and 11rmfas.in I,Cade:Any airy nr limn',
is hich"does aK nail to convouct.after.improve,demolh%li,or mpiry structure
ce,�-�� prod I ." alarequiresth applicantI hperratt fl asiged statement
dta) Inciarwilo rte' I thep f'he c t nosh I.R.(Chapmrq Sq. Ft. Floor Area NG Valuation
(conunencing with Section 9000)of Division 3 of the Bovinexs and Professions Code)
or men he i,emmpt Ihemourn and the basis far the alleged escmPtinn.Any violation
of Sadden 711.115 by a;y applicant fins a pvoniI subjects the npI)licam ii it civil penalty
of not mmm dl..use handrec dohax(550 0). APN Number Occupancy Type
01,is ownvl of the prvpeny,or my mnplaycen Is an wages au their still compenxutinn, nim
will do dm work,and the cmc u l is a..,unlaced or o1'1'ere1 far sale(Sec.7844,
Business and Nolessions Code me Con mom',Licmw Law docs not appy'to an ptequired Inspections
ow r of pmlwny Who build,or Improves daemon,and who does Inch work himself
r Through his own mnployoex.provided Ilial Inch ilmprmvemem,aK naI ore led or
ouerea for Sam.11,how'ev'er.the budding or imp evelnenl is sold widtin one year of 304 — ROUGH ELECTRICAL
uImpletion,the mwaer-builds.will have the burden of proving that he did not hold or
gmrvm Iter.....aw ter sale.).
01.as owner ofthe property,am exclusively contracting with licensed coneaamn to
....naca ILe pmjecl(Sec.70TL BIR nd Profess tnx Chde:)'Ute CI tractor's -
License law does not apply m an owncr propeny who hands or hnpmves Ibe,tvn,
and who contacts for such project,with a contractors)licensed pursuant to the
Cmm...oors License Law
01 ant es Inpl order Sec. ,11&P C In,this reason
Owner nam
WORKLR'S COMPENSATION DHCLARAI'[ON
I harcby affirm under penalty of perjury one of the following declarations:
O,Lhavc and will maintain a Certilicmc of Coastal m,dGinsum lin Workers
Compensation, as .....idled for by Sellinn 3701 of the Labor Code, for the
perkorinam"al ons wnrx Ii„will Inis perinb is issaed.
01 have and will in Amain Worker',Compensation Insurance.as required by Section
3700 of the Lubar Gxlc,for the per(nrniance or the work lie which this .mit is
nucd.My Workm's Gatq,cl xalr o 1114m,IlaCC carrier and Policy annabli are.
Carricr: Policy No.:
CERT IFICA'1'ION 01:11%EMI'I'ION FROM WORKERS'
COMPENSATION INSURANCE
!This section aeld nut he cmnplctal ifthe permit los fur one hundred dollars
(311X1)or Ica.).
I certify thus in the Iwrt nonce of the work for which this peal)is iLmed.1
shag no,employ any re-an in city I,o.w.nit as at her mmt subja:I to be W..was
Compensmom Law,ter Calif ..u Dae
Applicant
NO CE'10 APPLICAN 1:It.ndcrmmkmg Ihia Ccrtilicare mf Exenmaion,yam sbauld -
bsvonte whjvc,Ins the Worker,Cn I,...III provisions of IM Iatol Code,you mull
Q 0 forthwith e,imply wins such precision,it his shall be deemed revoked.
4 [Zi CONSTRUCTION LENDING AGENCY
I hereby affirm that them is a construction leading agency for the perfortmtwe
of Ibm walk for which his Ix`fnit is I..wd(Sec.397,Civ.C.1
L (� L came,,Name
.= z Lcuder's Addre„ .
J C I lel ily that I brave rend Ili,applicad...I and state that the dove iufonnminn Is
Le. F correct.1 agree it)comply with all city and county ordinances and state laws relating
O V
to biding construction,and hereby aiihorim representatives mnhis city to enter upon
the imcc.menhoned pnhpcny Em Ir,paetion purposes.
(We)a,.,,save.inbarmary sad keep annul...the City of Cupertino against
lin liabilities,judgments,costs and cs,vrw,which map in any way aarue against said
CI',in consequence of the grunting nr this pennh.
I� APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON IHIINT Issled by: 7T-?? Date
SOURCE REGULATIONS.
Signamrcmf Applicant/Conaall Ulllc Re-roofs -
HAIARDOUS MATERIALS DISCLOSURE.
WIII the,..dicer or lutnm building occupant store or handle hamWous ntemdat Type of Roof
use Jdired by the Cuhsninn Mmaicipah Code,Chaffer 9.12,and the I Icahn mad Safety
Cale.Section 25532(a)1
L Ye, 0 N All roofs shall be inspected prior to any roofing material being installed.
W311 the applicant or)mare building occupant use equipment or devices which If a roof is installed without first obtaining an inspection. I agree to remove
caul haardous air contaminants as defined by the nay Area Air Quality Management
• Dwriclr all new materials for inspection. Applicant understands and will comply with
O Yes No all non-point source regulations.
1 have read IM1e h rardous mmeriaM requirement'under Chapter 695 of the
Coli rorniu Ileallh K Set,',Cade.Scli ors 25505.25.533 and 25534.1 undertead Ihu(
if the building d«n not cunenlly Lave a¢nam.that it is my responsibility to unify the
occupant of the requitmocas which must be act prior to issuance of a Cenilicam of
O,,apy11vy' Signature of Applicant Date
Dwreralmd...ri.edagenl Dale All roof coverings to be Class "B" or better
OFFICE