04040057 (2) CITY OF CUPERTINO
BUILDING DIVISION PERMIT ,CONTRACTOR INFOR
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BUILDING ADDRESS: PERMIAN BUILDERS INC . PERMITNO.04040057
21000 STEVENS CREEK RD
OWNER'S NAME: PERMIT ISSUE DATE
lift IMWALLE STE 7_ILWEqTTm(-T-Tc)TTcTz. DR
NE: SANITARY NO. CONTROL NO.
(510) 979-9081
ARCH TECr/ENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MUCH
0 0 0 0
u0o LICENSED CONTRACTOR'S DECLARATION
rd U F 1 hereby amrm mall am httnsed under previsions Or Chapter 9(commencing Job Description
153 with Section 700)of Division Sof me Business and Professions Cadc,end my license is
n mmnmmeame0eC1' REVISION--IN HOUSE USE ONLY
o UiacMc z O
Dole CI.sContraaor
NO NEW PERMIT ISSUED/ORIG. 403100078
Y ARCHITECPS DECLARATION
�nu l understand my plansehali W used as publics cads
T O t; Licensed Profcssi...I _
g 3 OWNER-BUILDER DECLARATION
2<S I hereby affirm that I am exempt from Ne Contractor's License Law fur the _
00 following mason.(Section 7031.5,Business and Proremions Code:Any cilyor county
m which requires a Permit to construct,alter,improve,demolish,or repair any structure
prior to its issuance.also requires the applicant far such Permit o file a signed statement
that he is licensed pursuant to the previsions or the Contractor's Liccnx Law(Chapter 9 Sq. Ft. Floor Area Valuation $0.
F (commencing with Section 7WB)of Divisio0 of the Business and Professions Code)or
Q on
he is exempt thcrelrom and the breis far the alleged csemption.Any vi.1.6 a of
Section 7031.5 by any applicant for a Permit subjects the applicant to a civil penalty of APN Number Occupancy Type
not more man five hundred dollars(5500). P Y YP
I,m owner of the property,or my employees with wage.m their sole compensation, 35907005 . 00
will do the work,and the structure is not intended or offered for sale(Sec.7W Business
and Professions Code:The Contractor's License Law does not apply to an owner of Required Inspections
p cepeny who builds M improves thereon,and who does such walk himself or through his
own employees,provided that such improvements are not intended or ofrcred for sale.It,
however,the building or improvement Is Sold within one year Of CMMPlellar,the owner-
' builder will have the burden of proving that he did not build or improve for purpose of
sale.).
❑1,as owner of pr r ,am inclusively contracting with licensed eonmaors to
construct the pra' C. .Business aad Profeuous Code:)The Conmctmi Li
cense lewd pply tan sw, srarpmPcny ocentl p or improves Centra.ane
whocrnm et, or clip jecu with eco )licensetl pursuant to the Contractor's
License Law
❑tem es n �sc .B& C for @i�s/rcaz�on
er u ate 1 !iO
R'S COMPENSATION DECLA0.A
mby affirm under penalty of Perjury one of the fa ing declarations:
I hav and will maintain.CeniGcate of Cnnsen hiself-in.urefmWmkcr'aComPcn-
sation,m provided for by Section 37011 of the labor Codi for the Performance of Ce
work for which this permit is issued
❑1 have and will maintain Worker's Compensation Insurance,as required by Section
37W of the labor Code,for the Performance of the work for which this Permit is issued.
My Workers Compensation Insurance carrier end Policy number arc:
Carrier. Policy No.: _
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(TMs section need not be completed If the permit is for one hundred dnllium 15100)
it leas.)
I cenify that in the performance of the work for which this Permit is Wood.l shall not
employ any person in any manner as as to become subject to the Workers'Compensation -
Laws of California.Dam
Applicant
NOTICE TO APPLICANT:I[after Maki all this Ceni Bear of Eacmption,you should
become subject to the Worker a Compo herans provisions of she labor Code,you must
.JO forthwith comply with such provisions or Cis Permit shall be deemed revoked.
'Z�''-” CONSTRUCTION LENDING AGENCY
tr tom+ I hereby affirm that there is a construction lending agency for the Performance of
Cli 7 me work for which this permit is issued(Sec.3097,Co.C.)
Itl 0 Landers Name
D z Iander's Address
U 0 1 certify that 1 have read this application and state that the above information is
Ct. (•-r comet.1 agree to comply with all city and county ordinances and sum laws relating to
0U building con situation,and hereby authorise representatives of this city to enter upon the
r � .hove. endo cd property for rest.a..purposes.
e) me to save,indemnify and keep hornless the City of Cupcnino against
Arlo
ti� hold I s,j monis,costs and expenses which may in any way accrue agalm ecoid City
U 7 in n yes sof the grand rmit.
r7 S P C UNSER D WILL COMPLV WITH ALL NON-POINT Issued by: Date
Re-roofs
SixoZ, o pplicanUContractor Data
HAZARDOUS MATERIALS DISCLOSURE Type of Roof
Will the applicant ar future building resonant store or handle hazardous material
a defined by the Cupedinn Municipal Code,Chapter 9.11,and the Health and Safety
adsl,Lmda.se❑nirnYes 25532(a)1 No All roofs shall be inspected prior to any roofing material being installed.
7Will 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
1iL hmaNnus air contuminants m dcfned by the Bay Arca Air Quality Management all new materials for inspection.
mer, Ycshe ad the harandousmaeialsaquimmcnu underChapter 6.95 ofNe Califor
ca .fieryCode,Sccdons2 15.3}533and25534.1undcrsmndCatifthc building
t c udly ha thin itis met fumne..q.Ca ill of�crrpaney. Signature of Applicant Dale '
owner armarimaapent Date All roof coverings to be Class "B"or better