04010015 'CITY OF CUPERTINO
RuaolNCDrv)s)oN PERMIT qNol
BUILDINGADDRESS: I PERMIT N004010015
ER'S NAME: �j� . PERMIT ISSUE DATE
CUPERTINO HOTEL LT.(- V� n /06/21114
JNE: ;/ /'� SANITARY CONTROL NO.
�•+� 1 I/ ,
ARCHITECT'/ENGINEER: %` BUILOIN PER If INFO
B� ��ELE(7r UMB MACH
40o LICENSED CONTRACTOR'S DECLARATION Job Descri tion
O
M1 Wreby affirm Nal 1 am Iimosed under provisions a(Chapur 9(commencing p
with Smoon7l")of Division 3 of the Busiocasand Profcssinsu Code,and my license is
-ZoF in full f.mend effect HOTEL SIGNAGE
�? License Class Lie.Is
Dau Contractor
D
ARCHITECTS DECLARATION
1 understand my plans shall W used as public records
it
O Licensed Professional
OWNER-BUILDER DECLARATION
< I herchy affirm that 1 am exempt tram dee Contractor'.License law for the
i.00 following recon.(Section 7031.5.Business and Profession.Code:Any city or county
k S 1'i which requires a permit to construct,altar,improve,demolish,or repair any structure
°iy prior m its issuarm,010 requires the applicant for such Permit to fie a signed statement
ppF� Nat he is licensed pursuant to the provision of the Contractors Umnse Law(Chapter 9 Sq. Ft. Floor Area Valuation
yt$ (commencing with Section 70007uf Division Sof lbe Business and Prarisoms,Cade)or
y 3— Nat MIs exempt dtcn(rom and the thou for the alleged exemption.Any violation of
Section 7031.5 by any applicant for a Perth subjects the applicant In.civil Penalty of 3]f�$I3aIl5L$er0 0 Occupancy Type
.m mere than me hundred dollen(ss L P Y YP
0 1,as owner of the property,or my employees with wages as their sale c.mpcnaadon,
wuhlothewoh.anddeesuuct.reianutimm�&dmoRere forale(Sec.7W.Bonnea Re uired Inspections
and Professimu Code:The C.nwnor's License law doom not apply in an owner of q p
prepenywho builds or impraea therron,and whodoa such.,it himself.,through his
own employ=,provided deal such Improvements art not intended moRered fineala IL
however.the building or improvement is said within one year of completion,the owmr-
builder .will love the Wallis of proving Nal M did not lawld.r improve for Purpose.f
a.wmr of she pmpeny.am exclusively contracting with limnsed contractors to
construct du pmject(Sec.7064,Business;and Professions Code:)The Conuamne.Li.
come law d=not apply an an owmr of prapmy who builds or improves do mon,and,
who contracts;for such projects with amntracam(0 licensed pursuant to the Conoumr's
Liceve Law.
01 am sem�undm SSm..� .B&PClear srcon
r 11,141611"Dau
u
WORKERS COMPENSATION DEC ON
1 bemby*Rust under pensy of Perjury one of IIC 11wmS dechoollmse
1 have and will maintain a Certificate of Contacts,sel6iaum fm Wmker'a Compon.
"tion,as,provided for by section 37M of the labor Code,fm dta pedormame of the
wort for which this permit is issued.
0 1 have and will maintain Wohces Compensation Insurance,"required by section . .
3700.1'the labor,Code,fm Ibe perfermor of the work fm which this permit is Wood.
My Worker's Compcaatiom Insuranm carrier and Policy number am:
timer. Polity No.:
CERTIFICATE OF E)(EMPTION FROM WORKERS'
COMPENSATION INSURANCE
(Thu seNe11 need not les completed if she permit Is feronahundsed dollar.(31110)
or test)
I calmly Nat in the perfumlance of the work for which this Permit is issued.I shall not
employ any pcmm in any manner,",become subject to the Worken'Compenation
Laws of Califomia.Dau
Applicant
NOTICE TO APPLICANT:IL after making this Cenincau of Exemption,you should
become subject on the Workers Commutation prevision.of Ne labor Code,you must
O forthwith comply with each provisions m Nis permit shall be deemed mvo4d.
z "� CONSTRUCTION LENDING AGENCY
N
[—t I
ZD1'x tiQ hereby hthi Nal Nem is mossoutom lending agency
lnr the Performance of
wish for which Nu permit is issued(See 3M,Civ.C.)
Lactics's
Nrnc
ZD z Lender's Addrcu
U Q 1 certify Nat I have mad this application and ruse that the.thous information Is
LL Pcorrect.I agree to comply with all city,d county ordinances and sole laws relating to
O U building consioction,and herby Ndemiae repm.ematiac.of Ni.city to cntar upon the
[27 above-mentioned property for inspection PUMML
gy (We)agree to ave,indemnify,d keep harness the City of Cupertino against
1'/1 liablliticajudgmenu,costs and expenses which may in any way,cna against said City
in consequence of the granting of this permit.
PPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT Issued by: Date
ECURO REGULATIONS,
G•04 Re-roofs
Si nature of ApplicanUCanuador DIV—
HAZARDOUS
MATERIALS DISCLOSURE Type of Roof
tDisvWill the applicant or future building occupem store or handle hezutloa meuritl
xa?
e0rcd by the Cupertino Municipal Code.Chapter 9.12,and the Health"d Safety
e,Section 2ss3zar. All roofs shall be inspected prior to any roofing material being installed.
1 Cl Y" �Nu
Will the applicant or future building occupant use equipment or devi=which If a roof is installed without first obtaining an inspection,I agree to remove
hazardous air contaminants a defined by the Bay Area Air Quality Management all new materials for inspection.
DYca AN.
I have read the ha"nhwa materials requirements under Chapter 6.95 of the Coffin.
Health tit Safcty Code,Scctions25M5,25533,d 25x34.1 undmwtd Naif dtc Wilding
d=not curtcmly hove a unapt.Nal is is my responsibility to newly the occupant of Ne
re I n whichmuslbemetpdonulau,ccofeCcnOcemoregP�,ey Signature of Applicant Date
Owner or authorized agent - too y All roof coverings to be Class"B"or better