02050058 (5) CITY OF CUPERTINO h O
BUILDING DIVISION PERMIT 'CONTRACTR INFORMATION.
BUILDING ADDRESS: NORTHWEST SIGNS PERMIT NO.
20610 STEVENS CREEK BLVD
NE 'S NAME: 325 WASHINGTON ST APPLICATION SUB DATE
BER PROPERTIES, L. P. 05/09/2002
HONE: 831) 469-8208 SANITARY NO. CONTROL.NO.
ARCHITECIUENGINEER: BUILDING PERMIT INTO
BLDG ELECT PLUMB MECII
�00 LICENSED CONTRACTOR'S DECLARATION IOb Description
e d t hereby affirm un
shat l am licensed der Provi.itsm of Chapter 9(comme$GflP
encing
with Section](ags)of Domain.3n( sin
the Buess and Professions Code,and my license is
_eay I.fall lnmeandeffcel. SIGN PIER ONE IMPORTS
License Class Lie,M
0ya � Dam Contractor L_", pnr� E
^m—m4� ARCHITECTS DECLARATION :� I
C 'a I understand my plans shall be used rt
as Public cords !
u1Nk!u
�0 Lierroad Professional P
OWNER-BUILDER DECLARATION
ofI hereby allirm that 1 am exempt from the Contractor's License Law for the
In O0,O following rcusom.(Section 7031.5.Buainersand Professions Code:Any city lir county
mit
s $ which requires a per0a consumer,slkr,improve,demolish,or repair any structureX `
I—Z> Pnm to its isnod pumuani to r e pro applicarn,h,C.h.t,,iuLi tc a.ignc(Cha p int tLA
mm< shat me cing witpuuvannnthc provisions of the ComrenLicenelaw(Chopkr9 Sq. Ft. Floor Area $1091�ItlOn
that he
infora)Iand of Dessai.n3 oftheegeBusiness und Pm.Any violation
or
�
that he is exempt themGom and the bazia fur the alleged exemption.Any violation of
Section 7031.5 by arty applicant fore pnmit subjects she applicant toa civil penalty of 350999ibePO Occupancy Type
.at more than few hundred dollars($500).
❑I.as owner of Nc pmpeny,or my employees with wages as their sole compensation,
andwill doshe simas and the he Contractors
tors Lice se La ered fm of apply t an
owner
of
—
pro Professions Code:The Convector's License Law docs not apply to an owner of 10 3 - UFER equlred Inspections
property who builds i ed thavesthereon,sodwho dmesuchende himsetfor his
own empluyeWildin i orrithrovememproaumrnuare not intended lirllfered lw owner- ],04 — REBAR
however.the building or den of proving
is hold within oro year of completion,the owmr-
Wildcrwill havetheburdenofprovingNathcdid not Wild orimprovefor puryoknf 105 - ANCHOR BOLTS
sale) 304 - ROUGH ELECTRICAL
01,as owner of the propcny,am exclusively contracting with licensed contractors to 505 - FINAL ELECTRICAL
construct the project(Sec.7044.Business and Professions Code:)The Contractors Li-
n Law does not.pplyto.......f pmpeny who Wads or impsuws thereon.and 514 — FINAL PUBLIC WORKS
who comped,for such projects with a convacmr(s)licensed pursuant to the Contractor's
License law.
❑I am exempt under Sec. .B&P C for this M..
Orr Date
WORKER'S COMPENSATION DECLARATION
I hereby all'mn under penalty of perjury am of the following dcelansions:
❑1 have and will maintain a Cenificak of Consent to self-insure for Worker's Compen-
sation,as provided for by Section 37011,of the labor Code,for the performance of the
.,it for which this permit is issued.
1 have and will maintain Workers Compensation Insurance,u required by Section
3700 of the Ialmr CsMe,for the performance of one work for which this permit is issued.
My Warker's Compensation Insurance carrier and Policy number are:
Cartier: Policy No.: _
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
Crus section need no,be completed if Ibe permit is foram hundred dollars(SIM)
or less.)
I ccnify that in the performance of she work for which this permit is issued,I shall not
employ any Person in any manner m as to become subject to the WorkersCompromdr n
Laws of abramia.Date
Applicant
NOTICE TO APPLICANT:If.after making this Ceni ucam of Exemption,you should
Wcome subject to the Worker's Compensation provisions of the La Nu Code,you must
Oz forthwith comply with such provisions lir this Firm it shall W deemed revoked.
z O CONSTRUCTION LENDING AGENCY
[r 1hereby alEnn thor them is a construction lending agency for the performance,of
Ne,work for which this permit is issued(Sec.309.Co.C.)
Ila Q Lender's Nemc
P� z Lender's Address
U O I ccnify that 1 have read this application and stale that the above information is
LL. E' comea.I agree to comply with all city and county unbalances and sok laws relating m
Q U building construction,and hereby authorise representatives of this city to enter upon Ne,
W above mentioned propcny for inspection purpoks.
(We)eS.a m save,indemnify and keep harmless she City of Cupcninn against
w.t V) liabilities,judgmenu,costs and expenses which may in any way accrue against mid City
U z in consequence of Ne granting of this permit.
F-t APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT Issued by: Date
SOURCE REGULATIONS.
Re-roofs
sign.wre of APNkaO DateHAZARD
HAZARDOUS MATERIALS OISCLOSURG Type of Roof
Will the applicant or furore ipal Ca oe.Chapter
store or handle hazardous m.krial
az OeOmd by she Cupeninn Municipal CMe.Chapter 9.12.aW the Health and Safety
otic,Ses,on 25532(.)? All roofs shall be inspected prior to an roofing material being Installed.
❑Ye. ❑Na P P � Y 8 g
Will the applicant lir future building occupant use equipment or devices which If a roof is installed without first obtaining an inspection,I agree to remove
emit haxmdous air contaminants as debncd by the Bay Area Air Quality Management all new materials for inspection.
District?
❑Yes ON.
1 have read the M.Mloos materials requirementsunder Chapter 6.95of thc C.Plor,
Iia Health&SWety Code.Sectuds25505,25533 and 25534.1 understand Eatifthe building
Jens not currently haw a tenant,that it is my responsibility to notify be execution,of dm
requimments which must W met prior to issuance ofa Certificate 9fampancy. Signature of Applicant Date
Ownerormilibmwedagent Date All roof coverings to be Class"Ba or better