06030175 CITY OF CUPERTINO
BUILDING DIVISION PERMIT �. QNT"0'- 0112 NF,O®Rh1 .'t
'vw
BUILDING ADDRESS: DPR CONSTRUCTION INC PERMIT No.06030175
10123 N WOLFE RD
OWNER'S NAME: PERMIT L%UE DATE
LANDMARK PROPERTY MANAGEME T1450 VETERANS
E: SANITARY NO, CONTROL NO.
650) 474-1450
ARCHITECT/ENGINEER: BUILDING PERMIT INFO
71 BLDG ELECT PLUMB MECH
0 l�
op LICENSED CONTRACTOR'S DECLARATION Job DescriptionFFy 1 hareby SMM that 1 am licensed under Provisions of Chapter 9(commencing
with Section 7000)of Division Sof the Businnssnmd oI 'um Code,an9anylkeouls
�m nfull force ameffect. G�6 T. I . INTERIOR ONLY-COSMETIC STRUCTURAL/THEATERS
,qz LlaenreC LIe.M EXTERIOR SIGNS NOT PART OF THIS PERMIT
'CRDam Camrumr_
As shall k use DECLAR ATION
1 undcnunJ my plans shall he used u puhlic recnrJl
)lift
388; Licensed Pmfcssional
3 OWNER-BUILDER DECLARATION
)<2 I hereby affirm that 11. exempts an the Con ons;Ca License taw for the
.ISO fallowing reason.(Satan](131.5,Business and Improve,
d.ons COdc:Any city or county
which mquiros a permit w cnnNuc4 elmr.Impmm,demOlinh,or mpNr any aWclum
.iy prior m its issuance.also xquirns the applicant far such permit m rile a slgwd sulemenl
G that he is licensed purammi to the Provisions of the Contractors License law(chapter9 Sq.Ft. Floor Area V�igayiglg99
,/q
` $ (comu m mencingwithSecoon7000)Of Divuian3ofthe Busineuand Pmfrssio.Code)w I I I Ol T,
— that he exempt therefroand the basis for the alleged aaomp ion.Any violation of
Section 7031.5 by any applicant for a permit subjects the applicant at a civil penally of ppN Number Occupancy Type
net mare than Ove hundred dollars(S500). 31620067 . 00
❑1,as maner of the property,Or my employees with wages AS their sale compensadon,
will do the Small thoweasoae m not intended w offered far sale(Sm.7044.Business Required Inspections
and Pmrssslans de:CoThe Cantncmes Ltame Law don ret apply m an Owner of q P
property who builds w improv demean,and who does ouch work bimaelf ar though his
awn employers,provided thotueh improvements are not unmade l woffered for sale.If,
however,the building or improvement is sold within one year o(cnmpie ion,Ne awnns-
builder will have do burden of proving that me did ret build or improve for purpose of
sale.).
❑1.u Owner of the Property am eaalumaiY contracting with licensed cuntraman se
construct the project(Sec.7041.Business aha Pm(aslaru Cade:)The Coatrumis I.I.
cone law does not apply m an owner of property who builds or improv th mon,ad,
who contracts for such projects wins a eoaVaemns)licensed pursuant to me Comselah
LCCnY Law.
❑I am esempt under See .B h P C for this resume
norDam
WORKER'S COMPENSATON DECLARATION
1 handy affirm under penalty a(Majlvy aro of the following dalsutions:
1haveaha ids ma by aCean 3700 of Code.
ferefoe performance
of the
urian,ss provided(err rm Baton 3700 Of to Labor Cade.(ver Um perfannamx of the
work for which Nu permit is bound.
❑1 haw and will maintain Worked Compensation Insurance,as required by Becton
3700 of the tabor Code,for the performance of the work for which this permit hh Istem^
My Worker' Compensation brommoce ami.and Ptliq �number /
Cartier. C Policy No.: 1000 y
CERTI ATE PEX ONFROM ORKERS'
COMPENSA NINSURANCE
(Thu reelice need net Ise compl.ed Ore Permit Is(woes hundred dollars(SIM)
or lea)
1 century met in the peformanee of the work foe which this permit is issued.1 shall not
empicyanypenaninany......to becamO subject to the Worked Componadan .
laws Of CalifomiL Data
AMII.t
NOTICE TO APPLICANT:If,after making this Certificate of Exemption,you should
become Subject An the Waders Comperuaton provisions of the Labor Cade,you most
Oforthwith comply with such provisions or this permit shall be dared avoided.
Z� CONSTRUC ION LENDING AGENCY
EIherehyafr.dem Nem iso constructnn lending agency for the pmfortnaaa of
,7 the wad for which this Knit Is issued(Sec.3097.Civ.C.)
UJ ea
E Undoes Name
0 z Undee.Addr
U0 I cenify that I have rad this app ratan and tum Nn the to information u
Lt.P correct.l agree to comply with al try d unty ONinances and sum laws totaling to
0 U building construction,and hcreb prescntmiv or this city to color upon 0c
�C13 ahove-mentioned pmKrly far' a urposes.
(We)agree to ave,i dy d kap harmless the City of Cupertino ageinst
rFi y Iiabilides.judgmev assts d which may in any way ucrue againstsaid City
U z in cansegarme a BrSu n d' s Irnnil
APPLICANT D AND WILL COMPLY WITH A L NON-POINT Issued by: Date
SOURCER / G/
AP bb Re-roofs
Sillnuureo App nuactter Dam
US MATERIALS DISCLOSURE Type of Roof
Wi en Cupertino
Municipal
ngOmePantmmew handle Health de0ned by de Cupertino Mumriryl Cao.Qupmr 9.13,and the Halth and Safety
.Sermon 255324)7 All roofs shall be inspected prior to any roofing material being installed.
❑Yes ON.
Will the Applicantarfuture bud ding..Pant wcaquipmcal ordcdaa which If a roof is installed without firs[obtaining an inspection,I agree to remove
emit h ommus air emuminanu ss fined by the Bay Arta Air Oosllty Management all new materials for inspection.
Du ric17
❑Yes ❑N
Its-rc(joll ons 6.lsmquimmcnuundcrChapmr6.95oftmCxlifor-
niaHealthkS etsed 505,25533and73534.1undemmaddoadthe dtilding
data ret cu tln t. at itiv my responsibility m sooty f occupant of theregmre
to mon aaawe an cwrmamSignature of Applicant Date
f76% All roof coverings to be Class"B"or better
Owner auth i7, a eel
new