05090141 CITY OF CUPERTINO
BUILDING DIVISION PERMIT CONT.RAGTORAIV.EORMATION
BUILDING ADDRESS: WEST POINT SOLUTIONS PERMITND.05090141
10123 N WOT.FR Rn
OWNER'S NAME: PERMIT ISSUE OATS
VALLCO MALL 2292 1
E:
SANITARY NO. CONTROL NO.
(415) 643-5200
ARCHTfECVENGINEER: BUILDING PERMIT INFO
BLDG E
CtLECT PLUMB MECH
I� I�
ye z
+op LICENSED CONTRACTORS DECLARATION Job Df:SCllptlOn
IVC 1 herby70(affirm Wt I am licensed under Previsions me Chapmr Y(commcncing
with Sccuon]gKO ofDividon Sof Nc Budwv and Prat(evrimuCode.aM my
lkc�u
rt
in full foe and effect. 01'7D RELOCATING SEWER LIFT STATION
License Class Lk.N�ro Date
9
ARCHITECTS DECLiUEATION JJtJ.y+91.d6
1 understand my plans shall be used as public records
>e;U
s C H Licensed Prefcssianal
v' �� OWNER-BUILDER DECLARATION
<E I hcmby affirm Nat I aot wompt from No Commcmrs Ucence Law for the
p O following mason.(Section]M 1.5,Business and Professions Cade:Any citY of a unly
�.,V which requires a permit m cnm uct.alter,approve,demolish,or repoir any structure $75000
-p.0 prior to its issuance.also requires the applicant for such permitto file a signed sutement
< duo
Misliccmedpurscanuodmprovisoes ofdic Contractor's Ucusxlsw(Chapm9 Sq.Ft.Floor Area Valuation
E $ (commcncing with Section 70M)of Division J M the Business and Professinns Code)or
t r— Nal he is exempt 1Mrtfmm and Ne bum for NC alleged...mptian.Any violated of
Section 70]1.3 Dy arty applicant for a permit subjects Ne applicant to a civil penalty of JAW
not mart Nan five hundred dollars($500). F Occupancy Type
I.0 ower of the propraty,amY wployw with wgnuUe'v sok compenvdon,
will do Ncwork,and IhesWewm is nolinterlded IXoRered formic(See.7044,Business
and Professians Code:The Contractors Liana Law does set apply to m awns or Required Inspections
Own
Property who builds ofimpmva NemonaMwhe dassuNended dmulfur Waugh his r
etoo employees. or i Natsuhimprovementsissoldare not inknsWIXolkmd finish,owner. v �`
ntrieshowever.Ne building w improvement u mid within arc year of mprove for
Ne owner. /O
builder will have the borons of proring Nat k did not build IX improve fw puryux of
vie.). O
❑1.u awur ofij the Sce.property.am uclusivGy contracting with )Dic C somatises b 6
mnsouer d pmKa(Sec.n an BnsinessaMrtywho nsCode:) pro GOnaaeen. fad
who Ism does not h pr m m Owner a of enpraPu^y'who brills ss improves Norton.ms
who c e Law.for such pmjeas with a cantractor(a)Ilcensed pursuant to We Canuaaah
Licence Law.
❑lcon uempt undo gee .B&PCfor Nis moon
Owns Due
WORKER S COMPENSATION DECORATION
1 hereby aRm under,wally of perjury one of die following declarations:
sm and will maintain aCertifmcate o(Corec nt to self-imum for Worked Compcm
IC331.yIn(ft
,u provided for by Secuon 37M of W labor Code.for the performance of W
for which this permit is issued.
ave and will mainbin Workers Compewtion Insurance,u required by Smion
Labor Code,for Ne pcOcarmana o(On work for which dos permit u issuedorkers Compensation bourses catriv and Policy number art:
r. S'1T� Lv-M Policy No.: SZtLb(D2SN
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(Ions melon recd not 4 cmnpkkd U the permit is form,hundred dodos(SIM)
or kms)
I certify Nat in the pcffomiuts of Ne work for which this Permit in issued.I shill nal
esiploy any pesaan in any mamnrso u to become subject to tit WorkerCorepenmtion
Laws of California.Dan
Applicant
NOTICE TO APPLICANT:If,after making this Ccniftcae of Exemption.you should
become subject to On Workers Compensation previsions of the labor Code,you mnR
�+ foMwidt comply with such provisions or this Permit ahall W dames mvaked.
(7 CONSTRUCTION LENDING AGENCY
I hereby alRmt Nat dere is a consuvcfinn lending agency for the performance of
the work fw which this permit If useed(Sec.3097,Civ.C)
Iq �� Lenders Name
Lenders Address
0 1 I certify that I Mme mad Nis city
and
our and sink Nu the abnae information is
1 : 1^ COETML 1 o me ct comply with all ai f and county ordinances oa ens rote laws relating b
Cs Lj bbove-ocanstrwtian and bombs wNoriarepreunuuves ofNnsciq in enter uponW
ilel shove-menudgm propertycant rued epecGae purposes.
(,r (We)agree to save,indemnify and loop har elcas W City of C,nmrf.against
-(q liabilities judgments,8.ms6.1 Ofpensesrth. may In any wayamuagainst aaid City
in tI/ APPLLICANTeUNDERSTANDS AmND WILL COMPLY WITH ALL NON-POINT Issued by: Date
SOURCE ULATIONS.
^^ a z z�y('S Re-roofs
Sign—'Applicant/Conv r Dab
HAZARDOUS MATERIALS DISCLOSURE Type of Roof
Will W applicant or future building Occupant nom or handle huallouf material
as defined by the Cupertino Municipal Code.Chapter 9.13,and Ne Hindus and Safety
sale.section sssJ2(a9? All roofs shall be inspected prior to any roofing material being installed.
1 ❑Yes �(a
Will to applicut of future Wilding aavpam uac equipment or devices Mich If a roof is installed without first obtaining an inspection,I agree to remove
I7d-O
aurdnus air camaminmu u defined by Ne Be,Ansa At,Quality Management all new materials for inspection.
n? LL/
El Yea tTNU
1 have read the hoescous materials requirements unJerchapter 6.95ofNe Caliler.
alth&Safety Cade.Sections 255(15.253]]and 25334.1 urokramed Nucif W building
net currently have a tenon,Nat it is my responsibility to factory W occupant of Nc
ntart ykhmolbomelpi�/m� trarcof.Cerdrateofam>Ky. Signature ofApplicant Date
' " All roof coverin s to be Class "B"or better
ronutho'ncu agent DD2le - g