03110127 (3) CI'T'Y OF CUPEWFINp 7' = z ^= d% : ��:• ' + ' z«:
BUILDING DIVISION PERMIT CONTRACTOR INFORMATION
BUILDING ADDRESS: XL CONSTRUCTION PERMIT N003 110 12 7
ID991 N
R'S NAME: PERMIT ISSUE DATE
_AR ONE CREDIT UNION 1500 BERGER DR 11Z21/2003
PHONE: SANITARY NO, CONTROL NO.
(408) 271-2425
ARCHITEC(ENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
±00 LICENSED CONTRACT'OR'S DECLARATION TTT111
e w C 1 hereby affirm that I am licensed under provisions of Chapter 91e^mmencing 1It)bl}.gPpSription
ciw with Section 7UXb of Division J ofthe Rusin end Pmfessians Code,and my license is
n<n in full fn ticffttt �` (
i�= License cfx u'e.a SIGN
1 ou Darcy Cun c,r APR
2R; 14ndcrslandmypinsshalllinuSDsPuhlicmucos F1rIt 2 72004
Jou
e�G Licensed Pmfe,mmirol �pep,
` OWNER BUILDER DECLARATION U ■'e _�Y�i IIVG
<p I hemby affirm that 1 am exempt from the Cornaelors License Law brine
0 0 following reason.(Section 703 1.5.Business and Professions Code:Any city or county
``e m which requires a Permit to constroel,almr,improve,demolish.Or repair any structure $2000
pnonn illicuancc.alsortyvimslhc."H'ant for such permit to 0lcasigncd surement
< that he ishcenudpuamim ,, hepmvsi^mnnheCumracmrsLicenmLow(Chapter 9 Sq. Ft. Floor Area Valuation
2: 0 (commencing with Section70Xd or Division J of the Business and Professions Cook)or
2 3 that he is exempt Therefrom and the basis for the alleged escmplion.Any violation of
Section 7031.5 by any applicant for a permit subjects the applicant o a civil penalty of 1$N04h!rilbGrO0 Occupancy Type
not more dun five hundred undo..(S30R.
1,as owner of the propri or my employees with wages az their sole compensation,
will do the work,and the structure is nut outmoded or oRemd far salt(See.70M.Business
and Professions Cade:The Commdnr's License Law does not apply to an owner of Required Inspections
property who builds or improve thereon,and who does such work himself or through his
Own employees,provided that such impowernonu arc not intended or offered for sale.It,
however,the building or improvement is sold within one year of completion,the owner-
Wilder will have the burden of leaving that he did not build or improve for purpose of
sale.).
❑1,as owner of the property,am uelusively contracting with licensed contractors to
construct the project(Sec.70sa,Business and Professions Code:)The Contractor's Li- .
cense Law does not apply to an owner of property who Wilds or ImprnKS dKreon,and
who contracts for such projects with a contractor(s)licensed pursuant o the Contractor's
License taw.
I sea exempt order Sec. B&P C for this rcazon
Dam
WORKER'S COMPENSATION DECLARATION
1 hereby of nn under penalty of perjury one of the following declarations:
I have and will maintain a Cer iBeamof Consent to self-inxum for Worker's Compere
action,az provided for by Section 3700 of the Labor Code,for the Performance of the
work ror which this permit is issued.
❑1 have and will maintain Worker's Compensation Insurance,ns required by Section
3700 of the Labor Code,for the performance of the work for which Nis permit is issued.
My Workers Compensation Insurance canner and Policy number art: A
C. c,., lSHW4+e �olicy Nu.:�1.p' Q 'YJ' 310
{}v/ CERTIFICATE OF EX PnON FROM tiOR ERt�
COMPENSATION INSURANCE
(This section need not becomposed if Ibe permit is fm one hundmtl dollars(SI W)
or It..)
1 Certify that in the Performance or the work for which this Permit is issued.I shall not
employ any per can in any roomer so az to become subject o the Workers'Compensation
Laws of California.Date
Applicant
NOTICE TO APPLICANT:If,alter making this Ceni Reale of Exeminim.you should
become subject to the Worker's Compensnion provisions of the Lahor Code,you must
0 z forthwith comply with such provisions or this Permit shall he deemed revoked.
z2 CONSTRUCTION LENDING AGENCY
I hereby affirm that there is a construction lending agency for the performance of
2' > the work for which this permit isissucd(Sec.3097,Civ.C.)
:A Under's Name
z Lender's Address
U Q 1 ee tify that 1 have mad this application and sum Nat the above information is
ri t•-' carted.1 agree to comply with all city and county ordinances and state laws relating to
0 building conswction,and hereby euhorim rcprcxnutivra of this city to enter upon the
LL1 above-mentioned property for inspection purposes.
gy (We)egme to save,indemnify and hep harmlaes the City of Cupertino against
liaailities,judgmcn su and.barracs which may in anyway accmc ep.massid City I
Uz inconsequenecof a mnlingofthispermil.
^-� APPLICANT ON S NDS AND WILL COMPLY WITH A L NON-POINT Issued by: Date
SOUR L�Go
II1 PI04 Re-roofs
Signa rc nidieanvenntrictor one
HAZARDOUS MATERIALS DISCLOSURE Type of Roof
Will the applicant or future building occupant xunc or handle havarduus material
u Mfined by the Cupertino Municipal Code.Chapter 9.13,and the Health and Safety
Signori ss3a
Yeaxg No All roofs shall be inspected prior to any roofing material being installed.
Will the applicant or future building occupant use equipment or devices which If a roof is installed without first obtaining an inspection,I agree to remove
mill haeardous air contaminants as mimed by the Bay Area Air Quality Management all new materials for inspection.
District? �/
❑Yes ldtrvo
1 have read the M1a,Nnuxmamrials rcyuiremcnu under Chapter 6.95 of the Caldor- .
nix Hcalto Safety nmu]5N)5.25533and 2553a.l molecundthatifthe luilding
does not current a an that it is my responsibility m notify the Occupant of the
requimmcnc m pri iomm faccrdneamorOcce ySignature of Applicant Date
ow i,ndspent �re 3 All roof coverings to be Class "B" or better