08030137CITY OF CUPERTINO
BUILDING DIVISION PERMIT
,zC�NTRACTRURMATI,¢NN,
Buaplyt;IT"R WOLFE RD #2034
TBD — TO BE DETERMINED
PERM17f No.
08030137
OWNEIRUSINALM.SE:
PERh9T ISSUE DATE
05/01/2008
NE:
SANITARY NO. CONTROL NO.
ARCH=/ENGINEER:
BUILDING PERMIT INFO
BLDG EfECf PLUMS MECH
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LICENSED CONIRACfOR'SDEsimomf Chapter
Chile. 9
Description
P
1 hrseby affirm ivi 1 am f1 B under r4vf %of (commencing
wifullto n Profetuo Code. arcmylicenseu
COMM' L TI, BLD 3 RMS r EXM RMr CONTCT LENSES &LAB RM
nde(nfDmwon3ortbeeuurtevw
in full force and eOccL
License CIw IY. g
&
Date ARCHITECTS DECLARATION
ADD ON TO STORE FRONT
1 unJer4asl my phou, "I be used u Public rsords
Licrsved professional
OWNER - BUILDER DECLARATION
I hereby affirm that I am exempt from tM Contractors License Law for the
following mason. (Section 1031.5, Business and Professions Cade: Any city or county
which requlros l permit to curwrocl ales. improve. dcmulLsh. o mpur any luumme
! prior to its issuance, saw require the appliao for Such permit to rile a signed ruumem
that be Is licensed u the of due Corantaori 6 terse, Law (Chapter 9
Sq. Ft. Floor Area
Valuation
pursuant Provisions
(commencing with Sects m 7 000) of Division 3 of the Business and Professions Code) car
$50000
! Nat M is exempt tbemrrom and the basis for the alleged exemption. Any violation of
Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of
31620089.11AS* umber
� Occu arc Type
nmmore than five hundred dollars (MI.
P Y
❑ L u owns of ale popmy, s my wployce with wage u the'v w4 wmpcwtion,
will do the wort, and the shectum is notlnuncied oronered for sale (Sec. ]144. south
Required Inspections
and Professions Code: The Connors Litvam Law don not apply to am owner of
property who builds ar in, W over IMSean, and who dos such work hivuelf o Uuough has
owo employee, praNded rhvwcn improamemca ale not huxual oofere ! foul. B.
however. the Wilding or MproSanent Is sold within ow year of completion. the owner.
W +Ids will have the WNe of proving that he did rot Wild o improve far purpose of
sale.).
❑ 1, as owner of the property, am exclusively contracting with Oormed antracmn to
conserver the Miject (Sec. 7044, Buinw and Profeuens Code:) Tbe Contractors Li.
snow law doe not apply m an owner of property who Wilds or improve themen, and,
wbocontecu for such projects wish a comracum(s) lid pursuant to the Contractors
Lrsese Law.
m
Ej I aeempt under Se. ,B &PC for this wawa
Owner Date
WORKER'S COMPENSATION DECLARATION
P1 hereby affirm under penalty of perjury one of the following declarations:
, hxve and will mountain a Cerdfieateef Co.., to self -Insure fer Workers Campeo-
cation, as provided for by Section 3700 of do, Labor Code, for the porfarmwce of the
wok for which this permit is issued.
❑ 1 hoe and will mountain Workers Compermation Insu.. as mgored by Section.
3700.f the Latour Code, for the performwo Orthe wok for which thus permit is issued
My Worker amps such huurance carrier and Policy n b am:
Cartier. s Policy No.:
ERTIFICATEOFEX PITON FROM RKERS'
COMPENSATION INSURANCE
(Tnissemlm need st be completed OIbe permit is return, hundred dollars ($100)
or lee)
I certify that in the performance or do work for which this permit u+ssucd. I shall not
employ a" person in any manneru u to become subject to tbe Workear Compensation
Laws of California. Due
Applicant
NOTICE TO APPLICANT: If, after making Nu Certificate of Exemption, you should
become subject to the Worker's COmpewuon pruHsiuru o the tabs Cod, you most
foMwith comply with such provisinas or this permit shall W domed revoked.
-
CONSMucn0N LENDING AGENCY
-
1 hereby &Rrm that Vert is a construction lending agency for the performance of
the work to which INS permit is issued (Sec. 3191, Ch, C.)
lender's Name
'
,
Lenders AM.
I anify that I hose read Nis application end sue dead the above info undon I,
cones I agree to amply with all city and runty ordinances and scale lam m zing to
building construction. and hereby wtboria repmasushows of this city to enter upon the
lnnYCmejudmd for inspection which ma
(We) agree to am indemnify and kesp harmless Um City of Cupertino against
nproperty . no and soh +M may in try way acuue optimal said City
in of One
in cmmrguc'r of the granting of the permit.
of this Pe
APPLICANT UNDERSTANDS AND WILL COMPLY WITH AL NO -POIM
SOURCE REGULATIONS. ���
Issued by: Date /
,
Signuw or ApplmanUCanuacmr � p �"--
Re -roofs
HAZARDOUS MATERIALS DISCLOSURE a
Type of Roof
Will the applicant or future holding eaupat come, or handle nasudou moused
u defined by the Cupertino Municipal Code, Chapter 9.12 and the Health and Safety
Code. Section 25532(.)? VNm
All roofs shall be inspected prior to any roofing material being installed.
WIII the applicant or (atom Wilding aceurynl use equipment or devices which
If a roof is installed without first obtaining n inspection, I agree to remove
g P
it hararduus all cemamianca u defined by the Bay Atoa Air Quality Management
all new materials for inspection.
District?
C1 Y. )(No
1 have road Lou harsrdmm materials requirements under Chame, 6.95 ofthe Califon
nix Health & SetsYCOdc. Sections M305,25533 and 25534.1 urocrsrand Nat it tie Wilding
dos not currently new a unapt. the It u my responsiNlity he notify the =Want Of the
'
uxNim�aq =nmmmnelpp9lm1. nf,Cerufican,or
j g
Signature of Applicant Date
GL JSI5BtI 1W7b y
. All roof coverings to be Class 'W' or better
Owner or wNOrired agent
Dom—