07110163 CITY OF CUPERTINO �::•+ stt'Ea%..3»> f - ' t "%' '' `,
BUILDING DIVISION PERMITTRAC'"TQR INTORIVIrT,IQN.,:a
a.
BUILDING ADDRESS: PERMITNO.
1.0123 N WOLFE RD #2148 J T CONSTRUCTION 07110163
W NER'S NAME: PERMIT ISSUE GATE
CUPERTINO SQUARE LLC 1720 OCALA AVE #B 06/16/2008
ONE SANITARY NO. CONTROL NO.
(408) 234-434'0-_.
ARCHMIC(ENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
0 0 0 0
�Op LICENSED CONTRACTORS DECLARATION Job Description
rd u F 1 heresy affirm that 1 am licensed under provi ons of Chapter 9(commencing
`uj
with Section 7")afDivision 3 afft Businessi and Professions cont my Ikends 4 TI, MRS FIELDS-CABINETS,COUNTERS,BACK RM
in full fame and efren.
Dn— LlccmeClam I.ic.glgC� PARTITION, FLR,CEILING & WALL FINISHES, HVAC,
QQp Daa ARCHRECTs DECLA N ODIGY
2 I wdrwnd my pltm stall W used ns puhli record
54u PLUMBING & INSTALL NEW ELECTRICAL SERVICE &
bLL r Licensed Ptolessioml
5y3 OWNER-BUILDER DECLARATION
1 hereby affirm the,I am exempt from the Containers Liccnas Law for the
CaO following meson.(Section 70313,Business and Pmfessiam Cole:Any city or county
$ which rtquims a permit to cenawct.alcor.imProw,dcmollssh,or eInd,my stuctun
prim to is connote.ata rtquires the,applicant for inch permit to file a signed statement
S< that he aliened pursomm to the Provision of Ne Content's Liccnx Law(Chapter 9 Sq.Ft. Floor Area Valuation
yFg (combactreing with section 7000)of Oilmen 3 of he Business andl Praliessimas Cadiell.1 $103500
Q Ne Its is exempt thcmfmm and the basis for the alleged exemption.Any violation of
session 7031.5 by wary applicant for a Permit mbjcces dee applicant m a civil penalty of ��,,ppy7��t ppl�umber Occupancy Type
not mom roan fiw hundred dollars(s5Bt). 31620100 .Mli tS P y yp
❑I,uowncr of the propeny,mmy employers with wags sstk'vmle campewtion.
and dothesims andme he Comunms LMWor Law
apply
to ser Man,of Required Inspections
and property
who in Code The wes hmtarS License law dem mol apply tow owner q p
property who build a improves thereon,and who does stilt wank himself air through bit
own employees.prevlded Natmach imprewmmamat not ieandedoroQerod theca .B,
however,the ante the
olden of pmmt 4 cold within enc)ear of cnmew for Ise ewnm-
saldI. will have the burden of proving that he did cot build Or improve for purpose of
ssle.).
❑1.as owner of the papeny,me exclumnrly contracting with Remotest conuxtms to
construct the pmjen(Sec.7044,Bnsiness and Professions Code)The ConmeaorS Li.
cense Law docs not apply to an owner of property who Wilds or improve thereon,and,
who contracts for such projects with a contractor(s)licensed Fanuam be the Conuemh
Leaned
eand law.
❑Tametemptundr See. ,BBPCforthisreamn
ncr Due . .
WORKERS COMPENSATION DECLARATION
1 hereby aRimt under penalty of perjury em offt following declamations:
1 haw and will maintain a CWfintof Canxnt b xhRinsure fmWarkers Comped
sstion,as provided for by Section 3700 of the Isbm Code,for the performance bloc
work for which this permit is issued.
❑I have and will maintain Workers CompensadW Insurance,as;enquired by Section
37W of the LaWr Code.for the perimmance of the wdh for which this permit is issued.
My Workers Coope ation Wmance came and Policy number are:
Cartier. Policy Ne.: a'�
CERrIFlViE OF EXEASPDON FROM WORKERS' -
COMPENSATION INSURANCE
(roomed.need wnbecomplewd ifft permit is redone hundred dollars(SIM)
or leu)
I cerdfv that in the performance of the wmk for which this Pascal,is issued.l shall an,
employ any person in any mmmeran ar to Wwm:abject in the Workers'Cumpensaton
Laws of Califemit Dat
Applicants
NOTICE TO APPLICANT:If,site,making this Cenifiat of Exemption,you thmid
become Subject in the Wohera Compensation previsions of the labor Codc,you most
.J z foMwith comply with sash provieons m this Permit shall k dcemr4 naked.
? wr CONSTRUCTION LENDING AGENCY
[-+C Iheresy aMtm Wt the.is•comtucWn lending agency for the Performance of
a the work for which this permit is Wood(Sec.3097,Civ.C.)
alenders Name
.7 z Landers Address
U O 1 cenlfy than I haw read this application and mate that can,aWw information u .
Ir. F coneeL I agree to comply with all city and cowry ordinances and sate laws misting Is 1
QU Wilding comuuctinn,and hereby authman rtpmscntatiws or his city to cher upon the \.
akve-m.judgments.
propertyest for inspection purposes
4 (We)agree t sew,indemnify and Ideas hwrrom the City of Coporum.agunst
Uh
liabilities. orh.cosuand expcnxmmit. may in any wayuwe tgaimtssid Orly
U Z to APPLICANT
ofdEgnnWgofNuD WILL
/
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT Issued by; Date
SOURCE RBGULAT10ts15. �
aper— Re-roofs
HAZARDOUS MATERIALS DISCLOSURE AM Type Of Roof
Will
the applicant or future Wilding occupant am or handle hausdous material
as defied by the Cupenirt Mumeipd Code.Chapter 9.12,and the Health and Safely
49.0Ye�35572(01 All roofs shall be inspected prior to any roofing material being installed.
Will the aPplicml or future Wilding occupant use equipment or devices which If a roof is installed without first obtaining an inspection,I agree to remove.
emit air contaminants undefined by the Bay Area Air QUo ity Management all new materials for inspection.
❑Y (� u
I haw road the hadartimis materiatsrequiremenauotr Chapter6.95 of Ile Califon-
not Health hSafctyCade,Sections25505,25533 and 25534.I wdersand dedifthe Wilding
docs on currently haw•tion this it u my responsibility,t notify the uxupmt of the
requirements which most be(net poor t issuance of a Cc.flue of 0capamy.
? o� Signature of Applicant Date
Ower or wired w, D,t All roof coverings to be Class''or better
(L/