05090188 CITY OF CUPERTINO
BUILDING DIVISION PERMIT CONTRACTOR INE MATION .�
iu �t for F,. »^Ya.x'1ti.r.,i+,«a.✓,p tcwm" m k d
BUILOIHGADDRESS: SHRADER& MARTINEZ CONSTRUCITWO05090188
10150 N WOLFE RD
ER'S NAME: PERMIT ISSUE DATE
JC PENNEY 160 DRY CREEK 05
E: SANITARY NO. CONTROL NO.
(928) 282-7554
ARCHITECTAINGINEEW BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
0 0 0
u O o LICENSED CONIRACfOWS DECLARATION Job Description
I Wreby affirm Wt l am licensed under Provisions; m
of Chapter 9(comencing
with section 7")of 0iv1.mn 3nf dw Buainmr,and Proussum Cede,a myliccnmu
n In mu formVcffm 30-DAY TEMP PERMIT (ORIG.#05090158)
e8 Licenseelua Co.—g �XPIRES 10/27/05)
9 Car .
ARCHrMMCT'S DEC PHASE II)
1 undo d my plata Nall be used a public mmrN
5yU
g cad t; Licensed Professional -
3OWNER.BUILDER DECLARATION
1 hesehY aRm that I am exempt from the Cantraeefs Limnse law for the
O D following mason.(Secdon 7131_5,Business and Professions Cade:My City or County
$ which rectum•permit to co tm uct,afar,improve,demnluh.m mpoir any sgumuro
prior in its issuance.ansa requires de,happlicant for such Permit to Ole a signed statement< tical W is licensed porsuanno the provisions o(the Gontrmotl Lice=law(Gaver 9 Sq.Ft. Floor Area Valuation
$ (commencing with Section 7000)of Division 3 of the Buslnm and ProuSalons Code)or 214
.. that he u exempt therefrom and the bu i for the J
leged exemption.Any vioutlon of
Section 7031.5 by any applicant for a permit ubjects the applicant o a civil penalty of APN Number Occupancy Type
not mom than Ove hundred dollars($500).
❑1.as owner of the properly or my employcns with wages as then sale eompewtlon,
whlldo the work and thesnet.nnatinunded oreffered Imaid.(Sm.7061.Budnnv Required Inspections
and Prolong...Code:The Commcor's License m ro
Law exact apply m an owner of 9 P
property who bullds m improves tie.on,and who does such work hunself or through his
own employcu,provided that such Improvements ate not hounded araQered fmsels.IL
however,the Wilding or Improvement is sold within ore year of compleon,the ownu-
builder will have the Wrden of proving that he did out Wild or improve for purpose of .
sent,).
❑1.as owner of the properly,am"elusively convening with licensed con ramors to
Construct the project(Sec.7014,Business and Profraalam Code:)The Comnnm's U-
,C.Law dais ant apply to.n owner of property when Wilds or improv thermn,site /
who contracts for such pmjecu with a contractor(s)Iimnsed pursuant to the Contractor's
License law.
❑1 ore exempt under Sec. B k P C for this moon y
r Data
WORKERS COMPENSATION DECLARATION
1 Weedy affirm under penalty of peejury one of the following declarations:
ve and will mainWn.Certhftam or Consent to self-Insure fm Worker's Compen.
n,u provided for by Section 3700 of the Labor Cade,for the perfomanct of the
work for which this permit is issued.
❑1 have and will maintain Worker's Compensation Imuran¢,as requited by Section
3700 ofdhe labor Cade,for the performance ofthe were for which this permit is Issod.
My Worker's Cam Imur/sr,tn.1 P I number e•
Gorier. TE �E
CE CATE P ETON I N FRAM WORKERS'
COMPENSATION INSURANCE
(71tusection need not W completed If tW permit is forom hundred dollars($10()
m less)
I sonify that in the performance of the work for which this Norelt is issues.I"I nm
employ any person In any manger an as to become subject on detWorksn'Compensation
Lawsof Califomia.Dau
APPlieant
NGTICE TO APPLICANT:If,after making this Cceiamu of Exemption.you should .
become auhjm u the Worker's Compensation provisions of the arbor Come,you mug
.J O fe"with Comply with such Provisions or this Permit shall be deed ro
emvoked.
,.'Zen CONSTRUCTION LENDING AGENCY
[--t► I berebygrano that them is a Construction lending agency for the performance of
Ni
the.,itfor which this perch hsissued(Sm.3097.Chv,C.)
W�Q Lender's Name
.z Lender's Add.
U0 I ready that I have read this application and sou that the ebo.infom.mun Ice
U. . correct.I apes o Comply with all C d coumy aminarues and sou caws relating m
0 buildogconsamtion.andhe -mho .UP%'0 tivofthu city to enter upon NC
,�y W above-mentioned propen r impemhe uryases
L, (We)agree ro ,Indemnify d keep hamuss the of Cupertino against
).yy fiadlilenjud iso and ex Inch may Ino y amain against Said City
t) in mon: c gust f IAhs it.
PPLICANT ERSTAND N C PLY WITH ALL NO OINT ssued by: Date
SOURCER U TIONS.
VOWe-roofs `�-31.5�
Signso. fAppllmnVContracmr to
HAZARDOUS A RIALS DISCLOSURE Type of Roof
11 therapplicantor future Wildg occupant nate m handle huudcos mstedal
as define by the CupeNno MunlciW ode.Chapter 9.12.and the Health and Safety
1:1e, 25532(a)7 All roofs shall be inspected prior to any roofing material being installed.
e
Will thea Ikant or mom Wilemg .rat use cyulpmanl or devices which 'If a roof is installed without first obtaining an inspection,I agree to remove
hmamnus C ominanu Sa de0ge y Ibe Bay Arca Air Ouality MAmkemenl all new materials for inspection.
ia7
❑yes N
I vemgt u aurlabmqui nuunder .Chapterd.95ofthe C-llfon
nuHm 1Safny Code am125534.1mdernandthollthe Wilding
does n t gently be msponslbility m notify the encu tor
.qui me iswhich mut et poor rouser.Cndlkau of 4cc Signature of Applicant Date
O. rmaathendme 0 D�7 All roof coverings to be Class"B"or better