05120104 CITY OF CUPERTINO �'*�*'r %'�� x *' '�"'�' �' r "
BUILDING DIVISION PERMIT C®1 TRACTCR.I�3F,zOIiMATIONN
BUILDING ADDRESS: CHARLES PANKOW BUILDERS L DOM, NO.05120104
10123 N WOLFE RD # 2030
OWNER'S NAME: PERMIT ISSUE DATE
LANDMARK PROPERTIES MGMT 2101 WEBSTER ST 2006
E:
SANITARY NO. CONTROL NO.
(510) 893-5170
ARCHITECVEHGINEER: BUILDING PERMITINFO
BLDG EIECf PLUMB MECH
ipp LICENSED CONTRACTOR'S DECLARATION - Sob Description
w 1 bereby aRm that 1 am licenced under provisions of Chapter 9(commencing P
!Z, with Section 7")of Division 3 of the Business and Professions Crude.and my licence IS
'<e. in full CRccL 6 �� q7 Z MACY' S PARKING STRUCTURE
i'yr? Lieena elms —comnacter g ) FOUNDATION ONLY
ARCHI=f0 Date^C
ECI'S DECLARATION
1�� 1 ua
ndcrsnJ my phmsos,hel shtll k used as public rtcmds '
eyU
CG
Licensed Pmfcaianel
3 OWNER-BUILDER DECLARATION
<0 1 hemhy aRm on I 1 exempt from IW ConOns,Co License Law for the
❑O following meson.(Section?031.5,Business and Profession Calc:Any city or county
<$ which rtquinsapermit wcomvugShia.improvedolomitesh perniti ore a sig emy dssructum
p Wislcenenc.ausud to the the applicant for Sochpamitm Glc aligned 6akmcm
< Nat k is licensed punuanl m 0te provisions of the ConOacrorl lJcene law(CWpter 9 Sq.Ft. Floor Area Va10 9 0 0
e�0 (commencing with Section 7")of Division or the Business and Praressioru Cole)or
i? this W is exempt therefrom and the basis for the alleged.,do..Any vk,lada.of
Section 7031.5 by any applicant for a permit subjects the applicant an a dvil pcealty of qp Number Occupancy Type
more N
not maan five handled dollar(S50 B. 31620037 . 00
I,uo ofdcpmpcnymmymploymwithwagesathekmteeompct on,
will do the work.Slid the aWclun:k Wt intended oreRemd rot See(SO..?014.Business Required Inspections
and Professions Code:The Conuanals Liana Law does roet apply an an owner of q P
property who builds or improves thereon,and wW doessuch work himself urmrougls his
own employees.Provided that such impmsamenu art Wild in i or wfor Posies R. \
hevown.the building or improvement is Sold within one year of mmpkuon.cite ownv-
builder will have the burden of proving that k did net With m improve for purpace of
9k.).
❑L as Swett of the Sec.7 y,.B exclusively contracting with licensed nithai 's -
ce es,La the projcn apply
inOas,Business and property
who na;Wilds
Cade:)The Qua
mr's nd
cense law docs not apply e ts owner of property who Wilds ra improv Dem est and,
who concocts forsuch ryajeeu with a cankanar(s)Ilceued purwam b me Contramh S
am law.
0 C
I van exempt under Sec .B&P C for this moon
Owner Data
WORKER'S COMPENSATION OECLARATION
1 hereby afGm under penalty of perjury arc of the following denhu atioos:
I ham and will maintain a Cenificetc of Cronanl to sell-iuurc fm WarkcesCompen-
ation.as provided for by Section 3700 of dre labor Code.for the Performance of Jte
work far which this permit is Lewis.
❑1 have and will maintain Worker's Compmauon Insurana,as reyvimd by Secuon
3700.fthe tabor Code.far the pcdormua of the work for which this permit it issued - -
My Worker's n train.a comer and Policy mark,am:
-- � Policy No.:
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE r
(This ecetimt recd trot kcompkwd if the permit is fm one hundmddollars($100)
nr Ices.)
I certify Wt in me perforearrce of the wort for which this permit I,issued.I shall not
employ any person in any mannerso as to become subject to the Workors Compeuation
Law s of California.Date
Applicant
NOTICE TO APPLICANT:If,after making this Certificate of Exemption,you should
become subject in the Worker's Compensation provisions or the lake Cade.you muss
.J O forthwim comply with such provisions or thus permit shall k m
deeed nwoked.
Z CONSTRUCTION LENDING AGENCY
I hereby afErm WI there is a cmuuucunn lending agency for the Performance of
Cthe work for which Nis permit is issued(Sec.3097,Co.C.)
WLendcls Name
M A
z lenders Address
U0 1 certify that 1 have read Our application and state the Ile aWxe information is
!T. F-^ coma.I agree m comply with all city and county orcinalne,and sus laws tcima,to
pU building conswnion,and hereby smhmim presca.a,caof this city to cater upon the
property for
r LT] oleic-manuanea.Lcoup Adlinspection ws pis S.
(We)agree to ave,indemnify and p hamkss the City or Cupertino against
(aA liobiliucs.judgmcnu.cos dex nses itch may in any way attrm agafast and City
O z in cansequrxcof the ting is iL
^ APPLICANT UN A A WILL COMPLY WITH ALL NON-POINT Issued by: Date
SOURCE RE IU NS
S^3 —06 Re-roofs
Signazurc ofpli o Date
DOUSMATERIALSDISCLOSURE Type of Roof
Will the applicazr rfutum Wildiagoccuputsoremhandle hauNous mamrial
u defb¢d by the Cupenimo Municipal Code.Chapter 9.13,and the Health and Safety
Calc,Section 35533(a)?
Yes ON. All roofs shall be inspected prior to any roofing material being installed.
Will me applicant or ruturc Wilding occupant uceequipment ordevices which If a roof is installed without first obtaining an inspection,I agree to remove
iit hiealloes air cnnarnmeou as defined by the Bay Alex Air Quality Management all new materials for inspection.
Ulcl? '
Oyes u
I
lave
nus materiesrequitemants under Chapter 6.95 of the Ceirm.
nice Needs, ot 'mu 25505.35533 and 25534.1 uakrsand that if de Wilding
Jars note am.than it is my mpoodbility to nour,the occupant of the
reyuno ts met prior to ismance of a Ccrufwate of Occupancy. Signature of Applicant Date
Gw r Summit d agent Date All roof coverings to be Class"B••or better