02030097 (2) TY OF
CI
BUILDING DIIVIISIONNOPERMI CONTRACTOR INFORMATI
BUILDING ADDRESS: PERMIT NO.
21271 STEVENS CREEK BLVD HORIZON RETAIL CONSTRUC ION 02030097
'W NF.R'S NAME: APPLICATION SUB DATE
US PHYCAL THEORPY 1458 HORIZON BLVD 03/19/2002
t PHONE: (262) 638-6000 SANITARY NO. CONTROL NO.
o O O ARCHITEC,`ENGINEER: BUILDING PERMIT INFO
'w❑ BLDG ELECT PLUMB MECH L
yaUc _f IJ LJ ,
S
c z, LICENSED CONTRACTOR'S DECLARATION 1 thereby arum that I am licensed under provisions of Chapter 9(commencing Job Description
'•,� � withSeniod]GW)ofDivision3oftheBusiyessan P ry coae.anamynanrc DEMO .
ad I C IS In fYI m a RCct.
O i u Licere_ Lic.tr —
Da �- Commis r
3 u. ARCHITECT'S DECLARATION
I understand my plans shall be used as public records
i p 2 Licensed Profesetowl
OWNER-BUILDER DECLARATION
1 hereby affirm that I am exempt from the Contractor's License Law for the
following reason(Section]031.5 Business and Professions Code:Any city or county $3000
F O which«quires a permit to construct,alar,improve,demolish,or repair any structure,
ooet priors it issuance,also q re.Theapplicant for such permuta¢
o Ile a signed smem. - --- - ----- - - - - -
a. than tie'elatnsedpuikuammthe provisions of the Contractor's License Law(Chapter 9 Valuation
(commencing th Sxj on17,d00)-f Division J of the Balmess add Profeµ de)
tons Ca
or that he is exempt thercfrom0 and the busts for the alleged esemptimn.Any violation
--of Swim 703 L5 by any applicant for a permit subjects the applicant to a civil penalty
nor not more than five hundred dollars(55W). N0AR 9494�D INSPEC IQNS'`.-N(' Occupancy Type
❑T.as owner of the properly,or my employes with wages as their aide compensation.
'will'do'the work.'and'the strvaure'is'not m6aded or offered for sale'(Scc:7014,' Required IeChODS" '
Husincss'aud Professions Code: II$
:The Contractor's License Law does not apply to an 9 p
wiser of proMrtY Who builds or improves themeom and who d«s such work himself
0
or through his own cmpinyces,provided that such improvements are not imcnticd or
'completion.the owner-Wilder will have the burden of proving that hedid not build or •`lt.il .'. .0
prove for Pumposc of mlxj. _
_... ._- .__-.__ _
as owner of he property.am exclusively contracting with bar contractors to 'N'^'®��_. 1, t.(..."-
-- - stract the project(Sec.]014.Business and Professions Code:)Tic Contractor's
c ,
-- License Law does not apply to an owner of property who builds or improves Merton.
and.who.contracts,for.such projects witha.conuuantls)-licensedpursuant to fire ._..... .._..... .. ..- __.--..._MAY-3 1-2002- t.._._._...... .. ....... -- __ .. -----..._._ _..
Contmerora Licim c Law...-
- °l am exempt under Sec.'„ ,. �B&PCfor,thisrcason 'r'b t•r' ,.^..' :•
,. . ..,
Data BUILDING
WORKER'S COMPENSATION DECLARATION
= I hereby a1Rrm under penoliy of perjury orae of Ne following d«lerafions: -
° 1 have and wi11 malmaln a CerliBcam of Conseat to self-Insure for Worker's
i: Compcasalhim as provided for by Section 37W of the Labor Cads, for the
_ perfomunceof the work for which this permit,is issued.,
111 have and,will maintain Worker's Compensation Insurance,as required by Section
37W of the Labor Code,for the performance of the"work forwhichthis permit is
issued.My Workers Co ps s t o Insatiate c - d Policy numberam: ^-,.- _ - - _
.w __ .,.. _ -._ ..... _
Cir Jo1:S o ecIo2NS S:z7 n1
CERTIFICATION OF.EXEMPTION FROM WORKERS)„�”„4,i,, ., i N,p s-. iE? s. x y;t.•i;', L Yi I's .
COMPENSATION INSURANCE __,___- _.,__-_-„_ - --,•„ -_,_�-_„-,- „,__�,
(This section ncN not be'coodahe'd if the permit is for one hundred dollars
SHOW or less) .,
..n
I crfyemThat in Ne pert tali ' f fhd work for hiih f l pe t Work 1
o pop
stroll n t employ any pe any mvpic y� o thr Work n
of pa nto p/w[-, 111 7
.. I
in _ -__ ... __.. _ _ ... .._..._ _..
In ET n ovine of faborExemption,you should
rbcomes o to fe 'orker oions or
p eons ofthWn Cud,ytumusf
Q0 fonhwnN tom Ns revoked.
--
pro or permit shall bed recd
f'c ^ r 1l •CONSTRUCTION LENDING AGENCY
I h br Rrtn that th co I d ng agency fo Ne peAormentt `
of the Workfor-which thispmit
a ai sued ed s(ScrJ09] Civ C) .__ _- „_. .. ._ .. ..__ .. __... _..._ ..._. ........_
0 Q Leaders NvNe-... i ... .... _.r. _ .. ._ . ._..__. .._,.. . . .._...-.
Lender's Addiess' T-' 11
V' I ceNat 1 have read this application and state that the'aWve information is
U+''F 'confect. rtify I agree m comply with all city and county.ordinances and state laws selling
Q'tJ to Wilding construction,and hemby authorize representatives of this city to enter upon
'>,W the above-mentioned property for inspection purposes.,,
m (We)agree to save,indemnify and keep harmless the Ch('iif Cupertino against
-4 liabilities,judgments,costs and expenses which may in any way accrue apaimt said
City name,'uence'f the gmntin,of this permit.;'
SAP LICA NT UND NDS AND WILL COMPLY ONTH'Al NON- �`
RCE 1 ' D' .!•• ' Issued by: Date
jEname I=!ro act 'I'+
_ RDODS MATERIALS DISCLOSURE ,
w t r m ba la g as w t tore o naval nawdW t 1 Type of Roof_ ._ .. .-- -. . . :. --_7
as seer y the Cupenmo Municipal Code chapter 9.12.and Jin Health d Safety ♦\,` ,
Code'Sect on 255i2u) .'S Liar” 1'\ 1 ( '� !'. ' r 1•
All roofs shall be inspected prior to any roofing material being installed_
❑v« 5l {, > t - -----
Wll ppr.a f r f buildingoccupantu.ecgap t raev,t�a`wntn' If a roof is installed without firs[obtaining an inspection; ('agree to remove
ith doser nm ant df Wby the BayA ArQaltyMnagement
9�11176rrfla
rtt t ;. - all new materials for inspection Applicant understands and will comply w_i_th
°r. f: .. 1, all nof1- hint source-he ulatio
P g
1 hate-real Ne 1 a.mm renals requ rements under Chapter 6.93 of The
rt Health&Safety Code.'Section,25505,25533 end 25534.1 understandthat wilding dos not currently ha4ey.t ant,thin if is my responsibility to notify the'
be b
rat of the - ss.wl' C ” or . once of a C<riifcefc of
<u u' •
Dote ,.SignatureofApplicant g Date
�.
e - All roof coverings to be Class "B” or bette
Ow liar 6n'z r t' ; ,`. .
_.
. m .. _ .. ... _. OFFICE-