04060250 CITY OP CUPERTINO -. . '++ ' ,�•�
anNGorvlsloN :'. . . .PERMIT Ct)1�1'C.RA.C�`TUI2.IN C3RMt 'TO "- '` -.
BUILDING ADDRESS: PERMIT NO. '
J. T .CONSTRUCTION 04060250
OWNER' AM : - PERMUMUEDATE
SHOPPING GENT-13
E: ,', _ - SANITARY OL NO.
ARCHITEC(ENGINEER: _ BUILDING PERMIT INFO
BLDG ELECT PLUMB 'MECH
=
uoO LICENSED CONTRACTORS DECLARATION
Job Description
1 hereby affirm that 1 am licensed under provisions of CMpbr 9(commencing P ,
wi1.11feion]deffefpivislon3of Ne BuinuseM Profcasiou Code.and mylicense is
in full farce and effect.
5'y�z ueenm elaea� � ' Lk:0REVISION--IN HOUSE USE ONLY _
Y Date ARCHITECTSDDECCComrsenLARATION NO NEW PERMIT ' ISSUED/ORIG. #03100046
Y I umitoreand my plans shall M used as public rccend.
pc 0 .
3 Licensed Professional
OatNER-BUILDER DECLARATION
0 0 P hereby..an affirm that 11. exempt from the Comosnafs Liccmc Law for the
Count, -
O o following mourn. crit t ](131.5.Buinus and w,de inw Code:Any city or county
$us which requires a permit re enuwe4 pMt i t forsu demolish,or repro any structure
ummen,
�, thtrbuemsedp¢Immgmree the applicant for such Pemniurmensegned slakmcnn
ell
pursuantbthe pm Division
the Camncbr'aLcenmlaw(Ch:mar9 "''.`"f.j- Sq..Ft.-FIOOr`Alea. ,_Valuation
,x❑❑$
(commencing is exempt
with Become7")and t f Diwbn 3 the
the Busaged exeandmpt Prorcraon.Any vi Cade)of
e3.. NM M u eaempf Nme(rom and Ncbu4 for the alleged exemption.Any violation of
Section 7031:5 by any applicant for a permit subjects the awlicanuo;civil penalty of APN Number _ Occo ane T e
not mom Nan five hundred dolhre($500). _ P, Y YP
❑'L u awnn of the pmpeny,m my employees wIN wage u Heir sok compensation,
will do the Weak.And the muctum is not intended ora@red fanal.(Sec.]044,Business 31620037',.'00
and Professions Cade:The Cannot License Law docs nal apply b an owner of ._ - Required Inspections - .. . ..
property who W lldaarinwanows Neuron,and whodocssuh workhimulf or Waugh his
own employcu,provided Nat such improvements arc notinknded maRered for sal&If, -
however.Ne building or improvement is mid within ore year ofcompletion.the owner-
, builder will have Ne burden of proving Nat he did not build or improve fm purpose of
tile.). 4js
Costuas ownerofthe ctproperty,am,Business ely
crowning with )TheeC ronwor's t.
ronswn the project(sec.]naso Business and property
whWi Cade:)The Contractor's and, - S✓\
come Law dose not apply a an owner of property who builds or improves Neuron.and V
who contracts for such projects with acrnwcmr([)licensed pursuant to the Contractor's -
Li I .Law.
' ❑lam exam s ,Bj, ".m.148ansm
owner DaO K 'S MPENSATIONpECIARATIIMmbya rmunderpenaltyofpdutyoneofNefollowi : _
In.wandwillmaimainaCenifiakof ConsentbxlGinsumfor WarkesCompen- -
senior,as provided for by Section 3]00 of dw labor Code,fm Ne performance of Me
work for which this permit is issued. -
1 have and will maintain Wmkcrs Compensation Insurance,ss required by Section
3]00 of the Labor Codc,for Ncpetformenm of Ne woh for which Nis Permit is issued. - - -
My We Compensation Insurance Cartier and Polley number am: -
Carrier'. Policy No.:
CERTIFICATE OF E%EMPfION FROM WORKERS'
COMPENSATION INSURANCE
(This seeder wed notbecompleted lflM Ismail is forew hundmddollam($10L)
or leas.)
I certify that in the performance of the work for which this Permit is issued.l shall not
employ any person in my manner an u In become subject to the Workeri Campensaflon
Laws of Califomia.Oak
Applicant
NOTICE TO APPLICANT:If,after making this Certificate of Excmpfion,you should
become subject to Ne Worker's Compensation provisions of the labor Code,you mut
�z forthwith comply with such provisions orthis permit mail bedeemedmwked.
z O CONSTRUCTION LENDING AGENCY
[—i l hereby affirm that Vert is a couuunion lending Agency for the Performance of
!Yi Ne work for which this permit is issued(Sec.3097,Civ.C.)
W�Q Lender's Name
D z Lenders Address
U0 I certify That 1 have read this application and sok that the shout information is -
nr correct.I agree to comply with all City and county ordinances and Bute laws mlafing to
building construction.and wrathy authorize mpbsemadws of this city b enter upon the
�O
Lk7 above-mentioned properly for inspection purposes.
gya - (We)agree to use,indemnify and keep harmless the City of Copanino against
V) Iiabilities.judgmen4.costs and expenses which may in any way secure against said City
V z 4SOURCF
f Ne grant ,his permit. l
ser DER A A WILL COMPLY WITH AL N DINT Issued by: Date G'
T _ Re-roofs
licaHAZARDOUS MATERIALS DISCLOSURE Type of Roof
pplicant or future building occupant store or handle hasudous materiel
Cupertino Mun'Tal Code.Chapter 9.12,and the Health And Safely
Code,Section]Y.zs532(a)? "All roofs shall be inspected prior to any roofing material being installed. '
Yea Nu
Will the applicant or future building occupant use equipment or devices which If a roof is installed without first obtaining an inspection,I agree to remove
it heuNous air crnmminFurined by the Bay Area Air Qualify Management all new materials for inspection.
�� iatrict? - ,
O Yes
I have mad Ne hoodals mquimmenu undcrChapkr6.95 ofthe Califon
nice Hcalthlk Safely Cade,Scctiou 25505,25533 wd25534.1 understood thaif the Wilding
MCA
not eumenfly h t knena i my porwihilily m nod' occupant of Ne
myuimmenu whip I met cam of.Cerfifka o0c piney. Signature of Applicant - Date
w ,alhr'a sen, p m All roof coverings to be Class "B"or better