06060053 CITY OF CUPERTINO s^sect
BUILDING DIVISION PERMIT ocoNTRAYCTQ,RIN�I',.0C�TtMATI�N . .
BUILDINGADDRESS: DPR CONSTRUCTION INC PERM rNo'06060b53
10123 N WOLFE RD
R'S NAME: PERMIT ISSUE DATE
LANDMARK PROPERTIES MGMT 1450 VETERANS BLV 006
PHONE: SANITARY NO. CONTROL NO.
(650) 474-1450
ARCHITECT/ENGINEER: BUILDING PERMfr INFO
BLDGELECT PLUMB MECH
0 0
o o LICENSED CONTRACTOR'S DECLARATION Job Description
%to 1 Mreby grim Nat 1 am licensed under pmvisioru a Chapter 9(commencing
:2�5 wiN Section TM(l)of Division 3 of
ihe Business and Profcssium Code,and mylicensc is
<n inmOfo=andeffect. �9l�q{ ORIGINAL PERMIT #05060075
Date
License Class cont( REVISION: STRUCTURAL RFI
Dam 7SDE or
ARCHf7ECTS DECLARATION
1 understand my Plans shall W used as public records
JyU
°a� Liccnud Professional
3 OWNER-BUILDER DECLARATION
iI I hereby alTsm Nal i am exempt tram are Contractors License Law for the
O C following reason.(Section 715 1.5.Business and Professions Calc:Any city m county
e m which sequfres a permit to construct,altar,improve,demolish,or repair any ssunure
prior toils issuance.also nomirea she applicant for such Permit in file a signed sammenl
<
that he is licensed pumant to ft provisions or On Contractor's Liumme,Law(Chapter 9 Sq.Ft. Floor Area Valuation 0
G (commencing with Section 70(10)of Division 3 of are Business and professions Code)or
Oat he is exempt therefrom and the Isis for the alleged exemption.Any violation of
Section 7031.5 by any applicant lar a permit subjocs the applicant so a tivil penalty of �b]/7��`8giler Occupancy Type
net mare than five hundred dollars S5M). 3 16 2 V U S T.
0 0
❑1,as owner of the property,in my employara with wages in their sole compe,uadon,
will do the work and the structure is not intended or offered for»lo(Sec.7066.Business Required Inspections
and Protmiturs Code:The Contractors License law does rot epPly b e an owner of q p
propcny who builds in improve thereon.and whodoessuch weak him nfor Waugh his
own employees.provided thatsi ch imprewmens are not intended oraRered for We.If.
however,the building or improvement is sold within one year of completion,the owner.
buildm will have the bmdc"of Proving mat he did not build or improve for parynm of
sale.).
❑1,as owner of the property.am eadusively contracting with licensed contractors to
...I are Project(Sec.7014.Business and Prafessims Code:)The Contractors U.
cense IoW does not apply je an owner o(propcny who Wilds or impro'ar-a Corton.orsart,
who canteen for such project with a eontramaRlicensed pursum are e Contractors
Lkens taw.
❑lam exempt under See ,B&PC for this reason
Data
r WORKERS COMPENSATION DECLARATION
1 hereby aQsrm Under Penalty of Perjury and of are(allowing declandioev / y
❑I hsve and will maintain a CeNfieate of Commis to self-mi um for Worker's Compen-
staiom as provided rte by Section 3700 of arc labor Cade,for the performaax of the
work for which this Permit is issued.
❑ I rave and will maintain Workers Compensation Insurance,an mquimd by Section
3700 of the labor Cade,far in.performance of are work forwhich this permit Is issued
My Workers Compensation Insurance canner and Pull
Carrier. Policy N :
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE .
(Osu a than raced an,bccompleu:d if me permit is forms hundred dollars(SIM)
or less.)
1 certify Nat in On perfonmanm Of the work(or which this permit is based.I"I not
employ any person in any manner so as to become subject to On Workers'Compcvadan
Laws of California.Dam
Applicant
NOTICE TO APPLICANT:If.after making aro Certificate of Exemption.you should
become Subject to the Workers Compensation provisions of Ne Labor Code,YOU must
.JO forthwith comply with such provisions or this permit shall W domed molded.
z CONSTRUCTION LENDING AGENCY
[-� 1 hembyaRrm oras On.is.c.ason.do.lcndinpgcncy far the pmfurrnavac of
a > the work far which dJn pc.I,is issued(Sec.3091.Civ.Q
1 n~- lenders Name
7 z tenders Address
U Q 1 minify mat 1 hale mad this application and sum Nat the above information is
,y f'^ Cancer.I agree to comply with all city and cwnt�oNinunttsand luta laws relating to
0U almvcnmeansuedion.and namesaunnori ereprdemaslves or this city m cmcr upon the do
Hgyalwvrmcmiunar propcny for inrpccds. WV
(Wc)agmeso save,indrinm(y and pharmlesithc Cityo(CuperrinOagairm
r/1 liabilitirs.Judgmens.coss and�expcnva icM1 may in any way accrse againstsaid City
U z in consequence of the .'I this of thin it. v
APPLICANT UNDERSTANDS A WILL COMPLY WITH LL N-POINT Issued by: Date
SOURCEREGUL ONS.
Aeo Re-roofs
Signature of &IicanVCon nor Data
II DOLS MATERIALS DISCLOSUR Type of Roof
Will the applica or room Wilding occupantvoreorhandlo hamudous mamdal
defined by the Cupe 'se Municipal Cade.Confirm 9.12,and are Health and Safety
.section xss32(a)? All roofs shall be inspected prior to any roofing material being installed.
❑Yea ❑No
Will the applicant ar future building occupant use equipment or devices which If a roof is installed without first obtaining an inspection,I agree to remove
craft hexasems air Contaminants as defined by the Bay Area Air Quality Management all new materials for inspection.
District?
❑Yes ❑
I have mad are aiaN mamrialsmgsimmens under CTeP (6.95 o(th Cdiron
ri.No"b&Safety Codc.Sec6oss 25505.]5577 amt]5534.1 under dthuif Wilding
nes cot curemly Aaoanu WI it u mY rar-sPo�silnlity o n fY de Pant a!me
requirements-ch(nus metpsiartoissua,mcOfaC m OfOccu cep Signature of Applicant Date
6
OwAll roof coverings to be Class "B"or better
ner or amhon'ac0 agent Oata' '