01080099 (2) CITY OF CUPERTINO
BUILDING DIVISION PERMIT CONTRACTOR INFORMATION:
BUILDING ADDRESS: PERMIT N0,
7825 ORION LA 01080099
oNE NAME. B DATE
APPLICATION
CORP. yy08/20/2001
PHONE: SANITARY NO. CONTROL NO.
(Lv.o) -13-s�tz44
O m z ARCHITECT/ENGINEER:
BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
a i =1 1=J I.J L. I
8 y" Job Description
z LICENSED CONTRACTOR'S DECLARATION
1 hemby 0).d that 1 ant licensed under provisions of..Coidr. id(commencing TEMP POWER.
�SFo with full force
orceand ofect. onJathe Business and Professions CWc.and my license
6 m y� is in full force and effect.
z es w urea C1 uc.a J
X O a O Dae le C 11f�� Comricror
us 3 LL n '*a� ARCHITECT'S DECLARATION
F°'O 4 1 understand my plans shall he used as public recounts
f,2r
to 6 p O Licenced Professional
e� OWNER-BUILDER DECLARATION
='w I hereby affirm that I am exempt from tW Contractor's License Law for the
F z following reason.(Section)031.5.Business and Professions Cade:Any city or county $0
leo which requires v permit to construct,alter,improve,demolish,or repair any amcture
.5- prior to its issuances also requirestlrc toldicant for such permluo file a signed srammem - - -- -tc. hat he is licensed pursuant in the prov isions of the Contractor s License Law(CIripte,9 �yp� q,,,,��,,11 r Valuation
(commeitcing,wid,Section 7")of Division 3 of the Business and Pmfessionx Codd 36`�11r8 VY�.®�a
or in.,he is aetript therefrom and the basis for the alleged exemption.Any violation
of Section 7031.5 by any applicant for a pemtit subjects the applicant to a civil peralty
,..f all mom Otani five handled dauar.IS%)) 10 3APN tFEiNr Occupancy Type
111,as owncrol the pmpcny,or my employees with wages as their sale compensation, 304 —
will do the-work,and the structure isnot intended or oRcrcd'for sale(See:90 1. Required Inspections
Business and Ponessions Com, The Contractors License Low does not apply m e an 9 P
owner of property Who Wilds or improves thetmn,and w W does such work himself
nr throughfor
h- owe employees.provided that pmomm improvements t intended or
offcreefi sale:thoIf.nv however.thelhaveWilding ti P t Idwithin one year of - - --. r
improv'r the owner W(der 'll have the When of proving that he did not Wild or
improve rnr p.rpnm cd-le.),
.. .1..__ _...__..y.. . .c. _.._dc
us owner al the p(Sol ,n Business
yil Profeng ssions
Code) he Contractor's �. ..
con tract th p 3 t(Sic ](1W a .Ire d e f tone il s 1 The Contractor's ,
La I d t apply t net f proper who Wilds pro thereon.
< ' and bo.eo Ora is f , projects will - t' t rtsl.l J pursuant nr the ___. .....
Cot t L W
❑Tum exempt under Sec. ,B&PC fnthis.,an � N s -• �
Owner''. Dole `
' - WORKER'S COMPENSATION DECLARATION
`:, r•. I hereby affirm under penalty of perjurt.one of the following decorations: (�
❑ 1 have and will maintain a Certificate of Content to self-insum for Worker's
Coopensmion, as.providW for by Section 3700 of the Labor Cale, for the
_ performance of work fur which this tennis is issued.
❑1 M1abe and will maintain Worker's Compen dom Insurance,as majored by Section
3700 of the Wtror GNe,for the performance of the work for which this permit is
issued.My Worker's Compensation Insurance currier trod Policy numler are:
can 5Wf_Q..1 'Policy wx: 2XV0%-11-'Q1AQO. . ..--
t s CERTIFICATION OF EXEMPTION FROM WORKERS"
{ I• I ...
(ThtteednOMPENSATIONINSURANCE _ ,,,�'r ___
of W completed Bill,permit is for otic handred n doll t s}-t
(SIM)nr less.)
'.1•car.t y chain the jerfom.nce of the work fm which,5hi permit is iuuN,I
shall nm emptily any person in any manner sit ux m become subject m the Workers
Compensation Laws of California.Date
..APPlicant - - t .:_ ... . .. . ._-_. _.. ___._-_-
"NOTiCETOAPPLICANT:If.aflu..king thla Ccrificaenf Exemption,you smuld
Z become subject to the Workers Compensation provisions of the Lobs Code,you must
Q fd'nhwith comply with such provisions or this pemtit shall he deemed revoked. ,-
.F DO - • t" CONSTRUCTION LENDING AGENCY,'
ai ' r.l hcmby which this them is a c..ed Sce. lending agency for the peifonnance
ti Lender's Add r which this permit is issued(Sec.3W),Co.C.1
Q
Lead, Name ..e. . .tet .� . . .... �. ._.t.,...... .. ..- .
ass
U O I rectify that 1 have mad t k,typlica um and mute that the anove inlomwtlon is
Ice• ccrcm 1 agree,t complyth all city and county communces and state laws mining
Q to Wilding construction.a ndhereby authorize rcTtafvcvof this cityt toupon
the above-mentioned property for pert p rpo. . _
(We).9tlemnify and k ph the Cay fC len o against
N (lab i 3 dg ts, O e Pent which y anyway a CNC gam;) and
V Z. City de of lin"o h N t w`
SVII N T' DT SA ' WILL COMPLY WITH ALL M1OV PONT Issued by: Date O'�'•��
.- sow
signan fA .at do - , .Darr ' Re-roots
�'tIA US MATERIAL$DISCLOSURE
tll0e upplian ofutumhulldigrcespantsumor handle h:isLNuus mamri;d Type of Roof.. -
vs dcBrrcd by the Cu ino Municipal Code.Chapter 9.12,and the Health and Safety s t
Chide.Section 25512(.)^,:,..- I ;,I. .,r 11 '-i •'i's. .
❑Ye. .(• -- ❑Na' All roofs.shallbe inspected prior to any roofing material.being installed.
Sv'u me ppu� t rot hail. s ce p t meeq 'p t d a wh'eh If a roof is installed Without first obtaining an inspection, I'agree to' remove
coal,noodrital air contaffinarL5 as definad by the Bay Arca Air- Quality Management
District? all new materials for inspection..Applicant understands.and will comply with
ore. - ON. . alf"non point source regulations.
" 1 have read the h:¢aJous a iak neatmlcmenb under Ch,lci 6.95 of the
California Health'&Safety Code,Sections 25505.25533 and 25534.1 understand that _ -
iftheIcding Dues not<uncntly r runt. at it is-my rcipomihilitymnmify the
occupanttof the qu' ants ss a et prior m iksuanee of a Certificate of
m
., ✓: :Oce
Signature of Applicant _ - Date
'owamart gots _ Dam All roof coverings to be Class "B"or better
.. ...... .. .... - - - OFFICE . . . . _