04110133 (4) R
CITY OF CUPERTINO - r* ta �. ATI
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BUILDING DIVISION PERMIT 'X0NTRAC�TOINFORMON .- - --- -- ---
BUILDING ADDRESS: PERMIT N'0 4 110 13 3-
10581 CASTINE AV
'ER'S NAME: PERMIT ISSUE DATE
KANNE LLC 2004
ONE: _ ._. - .. SANITARY NO. CONTROL NO.
ARCHITECT/ENGINEER: - ---- .. -- ..- BUILDING PERMIT INFO
. BLDG ELECT 'PLUMB .. MECH .
L O pLICENSED CONTRACTOR'S DECLARATION
:�p U I bemby affirm Nal I am licensed under provisions at Chapter 9(commencing Job Description
with Section 7000)of Division 3 of the Busing and Professions Code.and my license is
R in fall fame and affect. DEMO (E) POOL
0n? Liana Class LIC,
=p
Data Contractor
D
- -- ' —
F'J' ARCHITECTS DECLARATION ...caeca...
n; I undersash
understand my plans shall he d m
e useu public eads
Das
LL Licensed Professional /
O S OWNER-BUILDER DECLARATION u
. I I herchy affirm that I am exempt from On Conuanoh License Law for the �g
00 following mason.(Secant 7031.5.Business and Professions Code:Any city or county
x m which¢yens a permit an construct.cher,improve,dcmnlah.ar repair any common V82500
:yah pilar N in issuance.also reBirea he applicant for such permit to file a signed statement __
h�< Thu he is licensed pursuant to the provisions of Nacturs e ComuLicenm Law(Chapter 9 Sq.Ft. Floor Area - Valuation
its-$ (commencing with Section 7")of Division 3 of the Business and Professions Code)at
.. Nat he is exempt themfrom and dre basis for the alleged exemption.Any violation of 11
Section 7031.5 by any applicant for a permit subjects the applicant m a civil penalty of qf0 0 Occupancy Type
not mart Nan five hundred dollars(g ). P Y YP
❑1,as owner of the Property,m my employers with wage ss Near ale compensation,
will do Ne work,and theounnum is not intended at offered fatale(Sec.70th,Business
and Professions Code:The Conuacmfs License Law does not apply to an owner of " a-'%` ;Required Inspections ..-
property who builds orimproves therm rand whodoes such work himself orthrough his
own employees,provided that such improvements see oat intended oro@fed formic.If, '
however.the building or improvement is said within ane yeu ofcompletion,the owner-
builder will have the burden of proving chat W did not Wild or improve for purpose of -
sale.{.
PJ.1,as owner of Ne property,am exclusively contracting wit licensed contractors to
41 consunn the project(Sec.7014,Business and Professions Cade)The Contractor's Li.
cense Low des oat apply m car owner of property who Wilda or improves themon.and
wbo contracts hough
pardons with
canuactor(s)licensed pursuant to the Contracmfs
Lmgm low.
0 Igo exempt under Sec. .B h P C for this resson
e �V 1 'Y `PEN n&,ARAT eN l�
I hereby affirm under penslty of perjury enc of the fol wing declarations:
1 have and will margin a Cerifica,of Consent m self-insum for Worker's Compen-
suion,as provided for by Section 37M of the Labor Code,for the performance of the
work far which this permit is issued.
0",I have and will maintain Worker's Compensation Insurantt,u required by Section
J]00 of the faWr Code.for the performantt of the worse for which this permit u issed
My We,
Compensation Insurance artier and Policy number am:
Cartier. Policy No.:
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(Thu section recd nm W complccd Buse pernit n far oac hundrad dollar(5100)
or las.)
I ccnifv that in the performance of the work for which this permit is issued,I shall at
employ any person in any manner so m of Wcume subject o the Workers''Compevauon
Lowe of California.Dale
Applicant
NOTICE TO APPLICANT.IL after making his Certificate of Exemption,you should
bttome subject m the Worker's Compensation provisions of Ne fa Wr Code,you most
.Jz foMwith comply with such provisions or Nis permit gall W dacmcd fcvokcd.
'ZOCONSTRUCTION LENDING AGENCY
7- I hereby affirm Nat then is a contraction lending agency for the performance of
G' > the work fur which this permit is issued(Sec.301 Civ.C.) _
W Lender's Name
a Lender's Address
az
V C) I ccnify that L have read Nix application and sum Nat the above information is
Ly.9 Correct.l agree to comply with all city and cwmy ordinances and sue laws cluing to
0 t-1 building announcing,and hereby vuthoriae ropmearsaims of Nis city to fact upon the
} 0. ahovcmcm¢mal property fat inspection purposes.
(We)agree to save,indemnify and keep harmless the City of Cupertino against _
tiN Iiabilaiu,judgmemu,emis and expenses which may in any way accme aggrusaid City
V z in consequence of the granting of this permit. _ 4DateU
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT Issued by:
SOURCE REGULATIONS.
t— 6/2;4f Re-roofs
Signal cof Applican n tor '
J ARDOUS MATERIALS DISCLOSURE Type of Roof
Will the applicanl of figure building Occupant gone or handle WArdous macaal
defined by the Caperton Municipal Code.Chapter 9.11,and.de'Health and Safety
OYo' 255324)?ea, ,` 'Na All roofs shall be inspected prior to any roofing material being installed.
Will the applicant or Tamm building Occupant use equipment or devices which If a roof is installed without first obtaining an inspection,I agree to remove
ami,ha>ardgus air contaminant as dcfincI by the Bay Area Air Quality Management all new materials for inspection.
D'svicl?
I have cad the hanfdnusmatcnals myuimments under Chapwr6.95 of We Califo,
ria Health @Safety Cwd,Secuuns 15505,25533 and Z53a.l undefsmnd that iftho building
dors not currently have a¢nam.door it is my raprnability,he notify me Occupant of the
equiremennswhichmug thin met proortoissuanceofaCcrtificatcoIOccup y. Signature of Applicant Date
h LL All roof coverings to be Class "B" or better
Oaner.Oc thorn gem Dam g