08010089 CITY OF CUPERTINO
BUILDING DIVISION PERMIT CONTRACTORINFORMATI
PERMIT NO.
eu1LLV r{O.A0.Dp.ESS: 08010089
WOLFE RD STE 1043 TBD — TO BE DETERMINED
NEWS NAME: 1V PERMIT ISSUE DAM
CUPERTINO SQUARE 01/15/2008
PHONE: SANITARY NO. CONTROL NO.
ARCHIIEC?ENGINEER: BUILDING PERMIT INFO
BLDG ELECT' PLUMB MECH
0 0 0 0
�oo LICENSED CONTRACTOR'S DECLARATION Job Description
j I W.b,Iflbm that 1 am focused under pmvisiom of Chapter 9(commeneml p
with Swdon7=)of DivWon3ofdu BusinmudProfessb cade.sndmyii,.—is DEMO OF INTERIOR PARTNS,CEILNG,RSTRM, PREF 4
.n r„ Licfavc e Tome and ellen
=z in a. IY.a FUTURE
k- Dem Conummr
A'R' DEcuawno
1 understand my Plana shall be used u Public mcords
a Licensed Professional
50 OWNER-exempt R ns not RATION
a 5i I hereby reason.(Em o n I em exempt from Ne Cmimus Co :Anse Law far the
o O which re ulnaa (Section 71171.5,Business and n,demolish,
Cade:Any city m county
$ whim requires a Permit m constroct,allm,improver,demallsh,m repair any suucwm
zy poor to its inuance,also mqumes te happlicant for such Permit m file a signnd statement
Net he is llccesed pursuenl to the provisions of the Cenllmmrs Cleave Law(Chap=9 Sq.Ft.Floor Area [. Valuation
3 h: somenclniwiNSeNon7000)ofDivuion3oft BudnmmdP r=iomCode)or $22000
Nn rte is exempt therefrom and the basis for Me alleged aaamption.My violation of
Seeders 7071.5 by arty applicant for a permit subjects the applivnt m a civil penalty W 316 2 0 0 3 7 A1I�jI+�umber Occupancy Type
sot mom thin fin hundred dollars(3500).
I,uawmr of the pvperry,mmY maPloycn with ngeaM thew sole eMnpewdan,
willdo the merle,and dtasructert ls notkunded or offered fertile(see.7044.Business
and Prefndav Cade:The CutrMmrs Limlus Law does nut apply man.of Required Inspections
promnY who baBda m im prow thermn,and who does such wart himself or through his
own cmploy ce,provided thatsach Impmwmmts me not Inunded oraRemd for sale.IL
however,the building or bnPmw race t is mid within ane year of emnplelion,the Manor-
build=will haw the Marden of proving that ba did nm build or improv fm purpom of
sal.j.
1,as owner of the property,am eaclvinly contracting with licensed rnnvcton to
cavtract the project(Sec.7044.Business and profaMfav code:)This contrmmrt Li.
cave law don not apply in an owner of property who baiks or Improves thartu,Md.
who contracts for such projects with a rn maxonis)licensed pursuant us Me,Contnctars
License haw.
❑Iunuempsundm See ,B&Pcr.mi. son
Dim-
40—
WORKEWS COMPENSATION DECURAT10N
— 1 hereby affirm under penalty of perjury am of the following dmluuiav:
9114/banned will maintain acaruOnu m Cali,in mlf-wo m fe woheYscompen-
Milan,at provided for by Section 3700 of the uhor Code,for tha performance of the
work for which this Permit is inmd.
❑I ban and will maintain Workers compensation Insurance,it required by Semon
3710 of the Labor Cade,for the perfamamce of the work for which this Permit Is lasued.
My Workers Compensation Ivurmx,carrier and Policy number am:
Cartier. Policy No.:
CERTIFICATE OF EXEMPTION FROM WORKERS
COMPENSATION INSURANCE
(This seam med tat beeomplemd Ifthe permit is foram httn@ WUm(3100)
Or leu)
1 unify that M the performance of the wart for which this permit ls iuved1 shall not
employ any person in my mannerm u m become subject to the Workerf&Pimadon
Lan of Califoml
NOTICE
o
NOI7CE TO�APPTJETA :I. m eni0cam of Exemption,you should
bmame subject m the Worker's Compensation provlsioas of Ne Lamm Cade,you main
O forthwith comply with such Provisions or this permit shall be deemed mvnked.
z CONSTRUCTION LENDING AGENCY
y -
[—t I hereby affirm that there is a construction lending agency for the PmformaMx of .
C > 0u work for which this permit is Lund(Sec.5097,CH.C.)
D1 lenders Name
z Lenders Mdress
V 0 I crstify that I hive read this application W sum that tic amen information I.
IL H torten I ogres m comply with all city and county onfinances and sum Ian relaring in
.G C.) building construction.and hereby tuthoda reprexaufins of this city in enterupon the
G amen-mmtianed progeny for inspection purposes
(We)agm to Mw,indemnify and keep harmles,the City of Cupcnino agaimt
Uin IkMmeaquedgmcnucomingofterunmit. mryInanynYamucagainstMiaCiq 2,,-ZAPPLICANT UNDERSTANDS ND WILL COMPLY WITH ALL NON-POINT Issued by:9 Date
SOURMc
ER noil�
ATIONS.rX& Re-roofs
Sinuum of
i pPlieanUCantran Data '�`--"-.
HAZARDOUS MATERIALS DISCLOSURE Type Of Roof
Will the applicant or future Wilding oavpmt a..rehandle haMrdous material
M defined by the Caperton Municipal Codc,Chapter 9.13,and the Health and Safety
.
Section 25532(a)?
❑Yes OD All roofs shall be inspected prior to any roofing material being installed.
Will tho applicant or future building occupant um equipment or dM lex;which If a roof is installed without first obtaining an inspection,I agree to remove
emit Warm.air commumalda u defined by the Ray Arta All Quality Management all new materials for inspection.
District?
❑Yes AN.
I have mal the Wind=materials requirements uulcr Chapter 6.95 ofthe Califm-
nia Health&SafctyCode.Seen=25705.25533 and 25534.1 understand Ihet if the building
lilI.not enrefldy haw a mune that II is my rnpossibility in or,the recap.,of the
yairtmcn 'c sea et poor t3suavaOfaCertifuauofOc�WrprySignature of Applicant Date
t�7=
wnerar authonrad ascot /Dam. All roof coverings to be Class"B"or better