06120017 CITY OF CUPERTINO €' 1�'}°` '
BUILDING DIVISION PERMIT C�1\11tC1C R �FO �T„cl ,p��,..,g
BUILDING ADDRESS: SAN JOSE CONSTRUCTION PERMIT"o.06120017
101
0 NER'S NAME: PERMIT ISSUE DATE
VALLCO LANDMARK 1210 COLEMAN AVE i2/nl;/2oo6
SANITARY NO. CONTROL NO.
(408) 986-'8711
ARCHnECf/ENOINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MEC"
0 0 0 0
iOp LICENSED CONTRACOWS DECLARATION
Job Description
U I hereby affirm cast I w loomed under provisions of CMpmr 9(com rte ming
with Section]Q'al)of Division 3af the Business and Professions Code.and my license is
'.�„ infull force anderra TEMPORARY PERMIT UNDERSLAB MINOR DEMO RESTROOM
,�i: LlcenseCleu Lc-N
rc Dam Connubial CORES
ARCHITECTS DECLARATION
i¢ I undersand my plans shall be used as public records
)yU
°Q� Licensed Pmfessianl
OWNER-BUILDER DECLARATION.
I hereby a?irm that I am comp,from the Conuacter.License Law for the
p o following moon.(Section]ID 1.3,Business and Profusions Cede:Any city or county
jle which requires a permit In construct,abet.improve,demolish,or repair any strYC,am
-iy pow in its issuance,a legWrei use applieann for such Permit a rile a signed mammenl
< Nat he is licensed purme n to the previsions of lac Comfxtoes Ucensc law(Chapter 9 Sq.Ft.Floor Area V4194 811 6 1 8
(commencing with Section 7(K)())of Division 3 of the Businessund Profeuians Cud,)or -
_
that he its comp,therfro a and the buis for the tllged eaempdom Any violation of
Section 7031.5 by airy applicant for a permit subjece,the applicant in a civil penalty of APN Number Occupancy Type
ne,roam than five handled dallam(seas,). 31620063 . 00
I,umvrs of the puvpusy,nmy employes with wages as thea sole rompensstion,
will do the work end theswcsurt u not intended aroRertd lrsal(Sec.]0.4,Business
and Professions Cade:The Contractors License Law does,net apply in in owner or Required Inspections
property who builds ur improm common,and who dao sato work mato ci f or through his
own employees,provided that such improvements am not intended oroQered forsals.If.
however.the building or improvement is sold within one year of completion,the owner-
builder will have the burden of proving cast he did rot buil or improve for puryuse of
sale.).
;"knivetuod
as owner of the prepeny,am eacloively...acting with licensed cmntrscmrs In
rucl the project(Sec.]Ow,Business and Profusions Cod=:)The Contractor's Li.
law docs not apply a an owner of property who builds or improves themon.and
onvects for such projects with a contraelor(s)licensed personas a the Contractor'sse law.
am eta under SecB&P C for this moms
inamWORKERS COMPENSATION DECLARATION1 hereby>Rnn under penalty ofperjury otmof the following dude.dons:
will maintain.Cmtifom of Consent to self-insure for Worker'sCompcn-
sation,u provided for by Section 3700 of dos labor Code,fm the performance of the
work for which this permit is issued.
❑1 have art will maintain Work,r's Compauation Insurance,as,required by Section
3700 of the labor Code,for the performance of the walk for which Nu pewit is issued.
My Workers Compensation Inmunum carrier and policy number am: -
Carrier. Poli,No.:
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(Ibis section need not be completed lithe permit is!none hundred dollars($100)
or less)
I ccttifv Nal in the perform..of the work for which this permit Is issued,I shall not
cmPlo;any person In any manner so at an lepop.subject 10 the Wnfkcrs Compensation
Laws of Calj;rR Date J2/6 jc�
Applican _r'1 LLaa—/�-
NOTICE TO APPLICANT:If,afar making this Cenifcaue of Emmption,you should
become subject he the Worker's Comp,uation provisions of the Labor Code,you mut
,J2 forthwith comply with such prnvisons or this pewitshall W decreed mw ked.
CONSTRUCTION LENDING AGENCY
.�.F Ihemb aRrm that there uaconstrucunn lending g a gcmy far the perfwmarmc of
IZ > the work for which this permit is issued(sec.3ovf,Civ,ca
Llj0 Lender's Namc
Z Lander's Address
U 0 1 ttmfy that 1 have read this application and sub that the shave information is
L•' coffee'.1 agree to comply wit all city and county ordinances and mm laws testing m
(D but lding construction.and hereby authorim representatives of Nis city to enter upon the
above-mentioned pmleny for inspection purposes.
Fa (We)agree to save,indemnify and keep harmless lie City of Cupertino against
h
liabilities.judgments.co.and cpcnsu which may in boy way acini against said City / �/�
C.7 z in Ie ANT=of the treating of this UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT Issued by: Date ,z—01-11 r'
SQ R GU A Ns.
- t, O(, Re-roofs
Sig of ApplicanOCommuclor Dal _
HAZARDOUS MATERIALS DISCLOSURE Type of Roof
Will the applicant ar f��uo"n' ingampansnom mhandlchuallou ma¢dal
U defined by the Cupenina Municipal Cad=.Chapter 9.12,and the Health and Safety
otic.Section 25532(.)?, All roofs shall be inspected prior to any roofing material being installed.
Yu. o
If a roof is installed without first obtainingan inspection,I agree to remove
Will the applicant or u'urt building occupant use equipment or tkviva which P g
it h—o ous all canuminans az defined by the Bay Am.Ail Quality Mauugemem all new materials for inspection.
District?
❑Yes
I have mud the ha>a mamamdab requirements undcrChapmr6.95oftheCalifor-
nia Hca11h&SafcryCod,,Sections 25M5,25533 and$534.1 understand thuifdc building
docs not cuwncay haw a mean.that it is my responsibility a or,theoecupo,of the
mwt ��hKh Spin'p arm trnroa acerdranmofO pmt,. Signature of Applicant Date
ods necathari>ma agent -- Date roof coverings to be Class "B"or better