02020045 (4) IiAIr Ur UUrbKIINO
BUILDING DIVISION PERMIT CONTRACTOR MORMATION:Alba
-
BUILDING ADDRESS: PERMIT NO_
02020045
OWNER'S NAME: APPLICATION SUB DATE
CALI REAL ESTATE PARTNERSHIP 02/12/2002
f PHONE: SANITARY NO, CONTROL NO.
E tZO ARCHITECDENGINEER: BUILDING PERMIT INFO
z w 5 BLDG ELECT PLUMB MECH
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N 2 LICENSED CONTRACTOR'S DECLARATION
D i_o I M1eab,.M.that l am licensed undery ov.anct of Chapter 9(commeneing Job Description
ml-ua wihseeartevprdefDivision3ofNcBusiirca}'anaProfessionsCodc.endmyliccnse INSTALL ONE ILLUMINATED WALL LETTERS .
� IS In full fes d R 1 ✓ -71
i O D —ARCHITECT
CoLicmm _
ARCHITECT'S DECLARAT
H g I understand my pram shall he used as public records
ia o O Licensed Professional
OWNER BUILDER DECLARATION
��- so so 1 hereby affirm shat 1 am<aamp from the Conmamor'r License Law for he
following muon.(Section 7031 S,Business and Professions Code:Any city or county'
D which requires a permit to construct,alter,improve,demolish,or repair any suucrom $4000
m-� pd.,to is iszuann,alsortquiresheapplicant for such permit lofsleaaigned stammem
a3- tMtbF,isliceaspapunuant ni edwiam,,.f the Contractors License Lew(Chapler9
w' Section 70001ofDivision3oftheBusiness dPrressiodacme '\`rl. Sq Ft-Floor-Area-,-., Valuation
(ofomm<ari9s.'@ and y ) t. t 1 j 'yt .
mm tie is exempt
-of miy a li Lol d fNme basis.fot rmhbjeaaltslatgh
:or not
morathan five hundred
dollars(5500). eed acpzpelmicpamiotao.eAcniyvivl ipoelantiaol ryn
' APN Number Occupancy
13 1.as owderof the rt.orm leas with boa<:as meiraole Tom rind, 101 — FOUNDATION t
grope Y YimP Y B panto
will do
ne the work,and o Code:Th is not imrntlm dr eeededLaw im'sate not(Sec. to an - -Bus - -- - -
Owner ss pro Poterty Who b cmc: improves
rovesContamens License o does
not apply m an Required Inspections'
Owner or property veno wilco w impm,ss hereon,and who d«s such work himself 104 - REBAR
or through his own employees.t budded that mp improvements are not one war of ..10 5 _-...ANCHOR- BOLTS.-
'-oRci<d'Tai sale.If,however.Ific builtlin or Ins tis sold within onc� -T - -' -BOLTS... -- - - � -�- ----
completion,
---
g en of proving
Years _
t improves for hcase of wilder will love he vetoedel proving Nat he did not wild or 304 — ROUGH ELECTRICAL '
improve for Wrpose of vla.h
_. .- _ 505 — FINAL...ELECTRICAL
ICAL .
❑nsuownerrojec property om<uWess add Profession,Nlic<nuhe Camic' m -
corewm'he present(s«.](a4,Owner o andsmwho b CmoOThr cenmeror's 514 — FINAL PUBLIC WORKS "
License Law arae"no apply to an owner of a cumin who holies se improves hereon, '
_Co who contract fLaw. pml<cu wins a<ommetor(s)licenud.purslum m the _ . .. . . - .. ._. .. _ - _ ... ..__.. .....
01
Contractors License Law.
_ ❑lam exemDl under Sec. - • ,B&PCfor this lesson .
Owner. Date. ...
WORKER'S COMPENSATION DECLARATION rL98nn /�k r, r.�D
( Ihereby affirm under amaltyoffierjury one ofhe following declarations: IIII�� II IVJ(�a5 ILI�ILyS.
g ❑ 1 have and will maintain a Certificate of Consent io self-insure for Worker's AUG 0 7 2002
. \ Compmmi
son, u provided fm00,by Second 3] of the Labor Codi, for the
- _ perfarmanc<of the work for wbkh Niz permit h issued. ;
❑I have and will diamond Worker's Comp<n'smion lnsuranec,'as required by Section
3]110 of me laver Code,far she pMomtence of the work for which coir permit is BUILDING
'. �isisJJ//ueE.My Worker's Compens lion Insuance certi<r and Policy number ort:
..... .. .. -.-. ._.-.e.--._ - - .- _ .....
CERTIFlCATIONOFEXEMNPROM WORKERS" ..r I �, r. z _ r .:� I �)�•"'
COMPENSATION EN INSURANCE'
(This rection need na M complexed if the permit is for one hundred dollars
(5100)or rev.) '
-1 teddy mat in the performance of the work for which his pemut is issued,I
shalt'not employ any Person in any marmer so as to become subject to the Workers
Compensation Laws of Cal ifomia.Date
.Applicant
NOTICE TO APPLICANT:IL after making his Cedifeen,of Exemption.you should " '-
Z become subject to the Workers Compensation provisions of the Labor Code,you must -
00 forthwith comply with such provisions or his prooth shall Ise deemed revoked.
CONSTRUCTION LENDING AGENCY
1 hereby alllrrn that here're a romsrpcdon lending agency for she pedomwrxs -
B>a of the work for which this permit is issued(Sec 309].Civ.C.) ,
r
A.:Q lender's Name' - .. . ..
D.:Z Lender's Address
r.1 C I certify shed I hats read his application and Stam that above information is
Bet Ea correct.1 agree tocomply with all city and county ordinances and state laws reading
�:U m wilding consuucton.and berebyautboriu representatives ofhis city to enter upon
W he above-mentioned property for inspection purposes.
Fi 0.• (We)agoce to save,indemnify and keep harmless the City of Cupertino against
Vl liabilities judgments cuss and espsaaal which may in any way serna,eg.iml siltl
U Z City m conzeque a he gundng of s,p m t. n /
AP L1CA'.T UND ANDS AN N LCOMPLY Wr1'H'ALLN V-POINT '' V
.S RCE REGUL •Z QZ Issued by: Date
gnomic of ApplicanUConuenor +' Dal Re-roofs
HAZARDOUS MATERIALS DISCLOSURE "
Will he applicant or future wilding occvpon,"ore or handle haurdobs material .Type Of Roof
as deSee .me COpm32(.)'ido Municipal Cmc,chapter 9.12,and he Healed dna Safety --
Code S<caon 255121 )
❑Yea �No - s.- '. .i
All roofs shall be inspected prior to any roofing,material being installed.
Will the a tc to comer buildingoccupantur<eaAirQua itdevloeserman If a roof is installed without fust obtaining an inspection, I agree to remove
cant hwnlous ant eomammams u defines by he Bay Area Air Quality Management
DlalnrxOYa, VNO all all new materials for inspection. Applicant understands and will comply with
all non-point source regulations.
1 have read the hziardoui materials mquiremenu under Chapter 6.95 of he
Cdifomia Health&Safety Code,Sections 25505.25533 and 25534.1 understand that
if the building does not currently have a tenant,that it is my responsibility to notify he
coup.t of the on, menu It h m t h cop prior m issuance of a[edifieam of
Occupancy.'
IZ �Z Signature of Applicant Date
Owner nr=oho v aLgentDate All roof coverings to be Class"B"or better
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