04060078 CITY OF CUPERTINO 77=,717
O
BUILDING DIVISION PERMIT MA
BUILDINGADDRESS: KR COMMERICAL INTERIORS INCE"'N"04060078
0605 N WOLFE Rn
OWNER'S NAME: PERMIT ISSUE DATE
HOST MARRIOTT 7r)4 N T;ATAVTA ST —nr / -2 /?
E SANITARY NO. CONTROL NO.
(714) 516-2100
ARCHITECT/ENGINEER: BUILDING PERMIT INFO
BLDG ELECTLEM MECH
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0 6 LICENSED CONTRACTORS DECLARATION
I iiifiI Chapter 9(commencing Job Description
I rDderaimenticaustelmdI
05 ,S n . "adim3coffloolituarm VO Professions Coda.a dinylicermis
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Zia- �ISIZcFy REVISION--BATHRM REMODEL
Dam— as 0 IN HOUSE USE ONLY/ORIG. #04020112
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Licensed Professional
OWNER-BUILDER DECLARATION
I hereby affirm that I am exempt train do Contractors License Law for the
MnO following momm.(Section 7031.5,Business and Prafectious Code:Any city or county
K which requires a Permit it construct.alamr,improve,demolish.or repair any structum
or
,Z�m prior ho its issuance,also requires the applicant forsuch Permit in rile a signed abnormal
Mat he is limmout former,to do provisions,of the Contractors Licanse Law(Chapter 9 Sq.Ft. Floor Area Valua
110 ft\%
(commencing with Section 7fall))of Division 3 of the Business and Professions Code)or
a. that he is exempt thourchiman and the basis far he staged exemption.An,ohilmi,an of
Section 7031.5 by any applicant for a permit subjects Me applicant to a civil Penalty of APN Number Occupancy Type
not mom than five hundred M.R.(MOO).
0 1,as owner of the pariperty,in my employees with wages as their sale compensation, 31647019 . 00
.1114.the work.end the instant,I.not intended Miyffd I...1.(Sm.7(1 Bonuses
and Prefousions,Cade:The Combatants;Lt..Law does not apply to an aeopeor of Required Inspections
property who builds unimportant damn stand who does such work himself orthrough his
own employees,provided that such improvements are notimended oroffered torsade.If.
however,Me building our Improvement is mid within one year of completion,she ovionar-
builder will have the burden of proving that he did not Wild or approve for purpose of
.10.
[]1,as owner of the Property,am combatively contracting with licensed contractors in
construct the project(Sec.7044,Business and Professions Code:)The,Contractors Lt.
more Law dms not apply 0 an owner of property who builds or Improves domain,and
who contracts for such projects with a mammonist licensed pursuant as he Commactor's
License Law.
0 1 am courapt under Sac, B At P C for this masom,
Owner Date
WORKER'S COMPENSATION DECLARATION
I thereby affirm under penalty of papy,one of the following declarations:
.,and will onfinum,re Cartilimbe of Consent to self-insure for Workers Comfort.
a inner,as provided for by Section 37M of the Labor Code,for the Performance of the
...
work for which gas permit is ismad.
we"
r I haw and will maintain Workers Compensation Insurance,a required by Section
I t
15311of Me Ube,Coda,too Me Mffom ne,of the wants for which thi,permit is issued.
My, a aces amium
My War mon I'd d Policy b( -
-7
are
e- Policy NJIW4�
CERTIFICATE OF P.7 EMPTION FROM W&WEIS'
COMPENSATION INSURANCE
OW;auction need not to complaint if Mai Permit Is formoloundauddollores($10d)
toss)
I modify that in the performance of the work for which this permit I.!..it,I almli no,
employ any person in my manner an as to become subject to the Workers Compensation
Laws of C.1ilarro.Dam
Applicant
NOTICE TO APPLICANT.If,after making this Costiricabi of Esemption,you should
become subject M the Worker's Compensation provisions,of the Labor Code,you must
z fordiwitio comply with such previsions or this permit shall M deemed revoked.
z 0
E 7) CONSTRUCTION LENDING AGENCY
IhcmbyaMr.Net there i¢amns.mc(inn lending agency lar the perfurmanm of
Me work to,which Mat permit I.issued(Sm.3097,Civ.C.)
til Q Leaders Name
gl�
z Under's Address
U 0 1 certify Mat I have mad MUS application and Stme that Me above information is
j,, correct lag=in comply with all city and county ordinances and stme taws minting to
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building construction.and hereby authorise representatives of this city in enter upon the
>I,W above-mentioned property for Inspection purposes
(We)agree to save,indemnify and keep harmless the City of Cupertino against
limilitletpilgrecars.c.sim and esteems which may in my way sec.a,dioutimid City
Z in camen,ance of Me granting of this permit.
AOULICEA��IIDE'RIT'ANDS AND WILL COMPLY WITH ALL NON-POINT Issued by: D�n()
SOURCE
R _U AT C
ON '7iek Yt
— Re-roofs It
gnat o
a Aplicen; wner Dam
H BOOKS MATERIALS DISCLOSURTypeTypeof Roof
Will quittiopliamc
c too..Wilding otem,ent a.re or handle Woundmis material
as 1.1imed by the Cupertino Municipal Cade.Chapter 9.12.and flue Health and Safety
do 6, ",32(a),
ode, a" A All roofs shall be inspected prior to any roofing material being installed.
❑ye: No If a roof is installed without first obtaining an inspection,I agree to remove
,a, ory
Willi Pitman, about building occupant use equipment or d"itia;which
19 havarmus air cormentrams,as defined by the Bay Area Air Quality Management all new materials for inspection.
dra,t?
Yes No
I have mail Me heard
f
Fl
11 us matuarrals requirements;under Chapter 6.95 of the Coulon.
.1.He.[%41 Safety Codi.Sections 1556.M533 and 15534.1 understood that if dic Wilding
Jona mam my hevcameant Nat iLumyresponsibility wnotify Jin=upmtorthc
mquire twhichnnum x ati poor to issummocar,ccoulimme.f!!cuPzWeiy�, Signature of Applicant Date
zml,_
o;t,fir area iized Seat All roof coverings to be Class "B"or better
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