06030112 (2) CITY OF CUr tiRTINO .
BUILDING DIVISION Pl,sRNIIT CONTRACTOR INI+ORMATION '
B UII.DING ADDRESS: RAM BUILDING CO PERMIT NO.061030112
1.0051 S DE ANZA BLVD
I VINER'S NAMC: PERMIT ISSUE DATE
MARDESICH COMPANY 1097 RIDGELEY DR 04 /10 /200f;
,.ME: SANITARY N0, CONTROL NO.
(908) 879-9756
ARCHITECT/ENGINCER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
10, LICENSED CONTRACTOR'S DECLARATION -
ut F I hcmby affirm that 1 am Ijcenud under provisions of Chapter 9(commencing Job Description
=W with Scaion]OrNl7 ufDjvision Jardre Businecx and Prufc it rte
_
Code.andmyliccns is
mr.ummcadc(rom
TENNANT IMPROVEMENT. COMMERCIAL SPACE
,qi License Class 'w" Lie o
.—
Dam Contra,., BANK
ARCHITECTS DECLARATION
i�< 1 undenenJ my plans shall he Ned as puhlia records
lyV
LL y Lit'Cnad PnIfCSSlana
'03 OWNER-exempt form
0 I haehy.(Tear on 1 oar exempt farm the Cnouns Cattle:
LiAny c Law for rhe
O O folloWhich mr reason.(Sacramouon consumer.
Business and Pmfunruls Code:Any city or county
tai which as issuance,
a permit to cnnsuua,alcor,improve,demnlL h,Fre pair any swaum ..ww
'I< pdonn imccosed c.alaego the mr,riancan,farfum such m Tilc a Law summcm ,y GQOOO
mm ultrming Wit punuenun me of Diaios of mehe Buricosan tanulsw(Ched0 tar Sq. Ft. Floor Area �� ll l
eFC (commencing with Scaftmar add of Divisionr ofmce,cd..sand Pmfetsio d Calc)tar
that he u aempn mcsfrom enJ me basis for me alleged exemption.Any vlalminn of (� 10,
Scajnn7001.5 by anyooploann for apmmit subjccu the applicant to.civil Knoll of APN Number YQ iu1p�a``ncy ype
not more Wan five hundred dollars($500). 35908018 . 00
V
1,as owner of the property,or my employees with wages u Nair ale eomperoun on,
Will do the work,and on,auunure is not intended or offend for nlc t5ec.7W4.B uainesr Required Inspections
and Pmfessios n wm e ns Code:The Convector's License law dot apply an owner of 9 P
propeny who builds or impmva Narcan,and who Ooeriuch work himulf ar tlwugh his
own employees,provided drat such impmwmcnks=nor intended aro@red foaale.IL
hmwavm.the building s impawmem brand wimin one year of mmplmjon,me awner-
builder will have dte burden of proving that ho did not build or impaw fur purpose of
ale.).
Q 1,as owner of the propeny,am aclurively contracting with licensed eanmaom or
conman On pmjca(Sce.7044.Business and Prormions Code:)The Conmcmrs Li-
..an L,w does not apply m an owner.(propcny who buildsm imps. Common,a0
who c.mmcu fo..ach projects with a c.nvact n(s)licensed pursuant to me Connector's
License Law.
El 1 am exempt under Sec ,B&P C fortis tenon
er Dam
WORKER'S COMPENSATION DECLARATION
1 hereby afBm under mourl y of perjury moa of the following dechoorkms:
I ham and will maintain a Cenificne of Consent to self-insum forWorker's Campno-
mtion,as provided far by Section 77W of We labor Code,for Ne pco omr.n.or de
work far which this permit is issued.
I have and will maintain Warmers Cc mprpr.um Insurance,as mquimd by Section
3700 orthe Labor Cale,Ge the performance of me work for which mis permit is issued.
My Worker's Compensation Insurance artier and Policy number am:
Cartier. Policy No.:
CERTIFICATE OF EXEMFFION FROM WORKERS'
COMPENSATION INSURANCE a
(Thus cJ nmMc if rte permit lr for enc hundred dailan(SIMI
.r Icss.)
I ccnify W in Che pe torment aft r far which Nis permit' on. .1 shell Dat
employ any rroni ray mann s sero be orub'car cation
A,,rlm u s
Appliann_ta
NOTICE TO AP L a0cr making Wis Cc ific c of Eacmption,you should
b...a auhjca Co the Worker.Co.pcns hom pa.jr m f the labor Cole,you Nun
.J O foMwirh comply wim sucA pmvinnm m Nis permit she m aeemea m.okad.
Z h CONSTRUCTION LENDING AGENCY
[-. I hemhy of 1.Wm Wen Is a connrntirm landing egenq for the perfumace or
�i We work for which this permit is issued(Sec.3097,Ci¢C.)
Wl.ender'a Name
fY Lcnder's Address
U O 1 mmiry that i have mad this application am send that tic above information is
Iy E" cancer.1 agme to comply with all city and County ordinances and Seem laws elating to
C U building mumnction,and hereby amhociae tnprcsenmrims ofmis city t0 enter noun the
Lc ahova. noun pmocny for inspection mpaus.
(We)ag •or Save,mdomnand p harmless me City of Cupenino against
F (n Iirtuh a,judgm ru,cosu anderDas wh'has any way amu.siamst said Ciry
f,)z incon gncnce fnccgaming of is per r.
^ APPI.1 NT (NDE STANDS ND ILL C LY WITH L NON-POINT Issued by: Date
SOURCE. ULA NS,
Re-roofs
HAZA
Sigwwrc of Applicali CoA rarer Dam
RDOUg MATERIALS❑atom SUhe Type of Roof
Will bytaCuNnnr future Wilding occupant he Ieh oulband Safety az al
de.Sm,by rhe Cupertino Municipal Codc,Chapmr 9.12.and me Hcalm and Safety
"dc,Scaian 2551]Wp / All roofs shall be inspected prior to any roofing material being installed.
❑Yes Na
wu me apprcat nr rmne bnndmg oaeapam as nlaipmenr ordevmes which If a roof is installed without first obtaining an inspection,I agree to remove
nit haianlous air cnIn
a0ncd by the Bay Area Air Quality Mmugemcm all new materials for inspection.
strict?
Ihav ad me smqu cmcnuoo&,C .9saftheCalirar.
ni Halm aretycos.xss3 adus34. rrmna mmlimeiv0dmg
d not aemly haiC is my r spa 'm y m notify ae ant of theeq 'no :nu wluah mlo Sara of asugae.1' allaet � Signature of Applicant Date
owner awhari'rcJagcnr 1 e All roof coverings to be Class"B"or better