05090059 CITY OF CUPERTINO
BUILDING DIVISION PERMIT CONTRAGTUMNFORMATONJ °�,
' .cu'.iJS N -
BUILDING ADDRESS: PERMIT NO.O S O 9 O O S 9
0123 hT WQT.7R. Rn
ERS NAME: PERMIT SUB DATE
LANDMARK PROPERTY MANAGEMENT
NE: SANITARY NO. CONTROL NO.
ARCH I'IECTIENGINEER; BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
30p LICENSED CONTRACTORS DECLARATION JbDescription
�j I hereby afflrm that 1 am licensed under previsions of Chamcr 9(commencing o
Ito Sected7f)(M)of Disda+on 3 afthe Bualnouand Profession,Codes,and my license Is r
n infullfomcmd racy J REVISION-BULLETIN 1 . FOUNDATION REVISION
Clm Lie.
Licence « SG9 9r�[6
Contractor VVIC, t M-a JXC` NO NEW PERMIT ISSUED/ORIG. #05060075
e A CHnELTS DECLARA7 ON
y I understand my plans Ndl W used as public rands .
30
G Licensed Pntteuimnd _
OWNER-BUILDER DECLARATION
I hereby easo .('Rens that 1 1. exempt from Ne ConuutoM1 License Lew.for Mbe
Do
Allowing reason.Permit
ND1.5, t.Business and Improve,
demolish,
Code:Any city structure 3$
width requires a peMmll m conatneL dmn improve,dcmaltsh,car repair any uncture
dpd.,anow he is
c,atsool1.Me Me provia icant entathr,mhpeter's 0lcasigmdsuumcal
i < that me cttesad Purmannt0ihepmvivsh of wacBusidssancenaeltio(Chapter Sq. Ft. Floor Area �'� Valuation
o (commenctngwiNSection]000)afDivislonJmftheBudrcuandProfcuiomCade)or $0
3 Net he is exempt Membered and Ne basis for the alleged exemption.My violation of V
Section 7031.5 by any applicant for a Penn+,subjects Use applicant to a civil penalty of APN Number cupancy Type
nal man Nan Eve hundred dollue(3500).
❑I.as murder or the property,or my employees with wagnu their old compensation,
will do the work,add themdIs not nw
intended or offered roale(See.7061.BnaiMs RC aired Ins ecti0I1S
and Profession.,Cade:The Contractors License Law does not apply be an owner of q P
pmpenywho builds w impro.thrnon,and wbo daeeseehworkhimddf orthreugh hu
own employees.provided that such improvements art notimended croQered(mule.if.
however.Ne building or improvement Is Bald within on:)ear of completion.Ne owner.
builder will have du burden of proving that he did rot build or improve for purpose of
cele.),
❑1.as owner of the property,am exclusively convecting with licensed convectors to
common the project(Sec.7064,Brained and Wafnsiaes Code:)Tru Contractors Li.
counts Law does not apply m in owner of property who build,or improve Marcos.ad.
who contracts for such prejeeb with a emtrachads)licensed personal a the Contractor's
License Law.
❑I em exempt under Sec. .B&P C for this reuan
r Data
WORKERS COMPENSATION DECLARATION
I hereby alfina under peadly of perjury one of the following"Mdam:
I low end will maintain a CerdfieeumfComent to self-Imam for WorkeraCamPen-
ulion,u provided for by Section 3700 of tie Labor Code,Tal Ne perfonnsue,of Men -
work for which this permit is added.
❑1 have and will maintain Waftes Compensation Insurance,u required by Section
3700 of the labor Coda for Me pnfamrance of Mu work forwhlch Nis panni,i,bused.
My War Y,Cmn emadonM ceoiu ur/d�y/oi�ry number�me:
tinier. t
CER7IFlCA OF EXEMPTION FROM WORKERS'
COMPENSATIONINSURANCE
(Tho section need not becompleted If the permit is formic hundred doRm(3100)
or less.)
1 certify that In We performance of the work for which this permit is issued,I Nall not
employ any person in any manners as to become subject u Me Workus'Compensation
Laws of Caledonia.Dau
Applictnt
NOTICE TO APPLICANT:If.after making this Certificate of Exemption.you should
become subject to the Wolters Compensation provision of the Labor Code,you must
,J O forthwith comply with such provision or thin permit Nall be deemed revoked.
Z CONSTRUCTION LENDING AGENCY
(~ Ihembyaffirm the,then u a commuctinn adding agency for f performance of
C> the scat for which this permit 4 issued(Sec.3097,Cin C.)
W�Q Leaders Name
Z Lenders Added
U Q 1 cnn+fy Nn sou Met have reed this application and sothat Information show Infaution b
is, !' correct.I agree to comply with dl city and county eminences and soon taws diming 10
CSU" building consWction,and hereby mNorm,repnxnudve of this city to enter upon ft
fy above-mentioned property for dependent puryosea
(we)agree to move.indemnify add keep humorless the City of Cupertino against
P. liabilities,judgments,cum and expenses which may in any my M:7,said City
V 7 o onuquemeofth ynnting of this permit.
F7 APPLICANT UN ND L COMPLY WITH N OINr Issued by: Date �-122 r_ "
SOURCE REG 0f
Re-roofs >1
Signature of Appl+cen✓Comnctm D u
HAZARDOUS MATERIALS DISCLOSURE Type of Roof
Will the applicant or future building occupant dare or handle harudow mtecrial
OeOdo by the CupeNnm Munici I Cade,
Gaper 9.12.add the Health and Safety
Section 25532()1 All roofs shall be inspected prior to any roofing material being installed.
7MM,i ❑Yes Nu
Will the applicant or future Wilding occupant vac equipment or devices which If a roof is installed without first obtaining an inspection,I agree to remove
ct?
hamm�es air conumiosns u defined by tlm Bay Area Air Quality Management all new materials for i spection.
❑Yes1 have road the hvardwsmauriats requirements underCapter 6.95 ofdu Celifor.ealth&SdctyCoese,Seeoos 25505,25533 add 25534.1 undcamnd thairMc Wilding not currently have a damn,Net It u on paesiIdly,to dad fy tW peal the
rementswhienppAWic r +d craaNnmmofpr�Mry_ _�` Signature of Applicant Date
ownereramnonv%�d////a�//k(�f//�n��1 Zr D�e`w All roof coverings to be Class"B"or better